Chapter 33: Lower limb orthoses for persons who have had a stroke

Question 1

What are the two major pathological types of stroke?

Answer 1

Intracerebral hemorrhage

Cerebral infarction

Question 2

What percent of strokes are cerebral infarctions?

Answer 2

80%

Question 3

What are the four subtypes of cerebral infarctions?

Answer 3

Lacunar infarct (LACI)
Total anterior ciculation infarct (TACI)
Partial anterior circuation infarct (PACI)
Posterior circulation infarct (POCI)

Question 4

What is a lacunar infarct?

Answer 4

Pure motor stroke, pure sensory stroke, sensorimotor stroke or ataxic hemiparesis.

Question 5

What is a total anterior circulation infarct?

Answer 5

Combination of new higher cerebral dysfunction (dysphasia), homonymous visual field defect, and ipsilateral motor and/or sensory deficit of at least two areas.

Question 6

What is a partial anterior circulation infarct?

Answer 6

Only two of the three components of a TACI, or with higher cerebral dysfunction alone, or with a motor/sensory deficit more restricted than those classified as LACI.

Question 7

What is a posterior circulation infarct?

Answer 7

Any of ipsilateral cranial nerve palsy with contralateral motor and/or sensory deficit, bilateral motor and/or sensory deficit, disorder of conjugate eye movement, cerebellar dysfunction, or isolated homonymous visual field defect.

Question 8

What are the common features of stroke?

Answer 8

Changes in resting tone
Spasticity
Weakness or paralysis
postural deficit
Loss of proprioception
Sensory deficcit
neglect
cognitive, emotional, intellectual impairment.

Question 9

What is hemiparetic gait?

Answer 9

Slow and stiff, with a reduction in both cadence and step length.
Poor coordination of movement leeads to primary and compensatory gait deviation and an increase in energy cost.

Question 10

Hemiparetic gait is markedly what?

Answer 10

asymmetrical, with the stp length of the affected limb greater than that of the unaffected side.
If often has tone induced equinovarus
Knee hyperextension is often present
Tibial progression in second rocker is impeded due to plantarflexion
In swing, hip and knee flexion are reduced along with dorsiflexion.

Question 11

What muscles are absent in a patient that should be given a posterior leaf spring AFO?

Answer 11

isolated weakness of the dorsiflexion muscles.

No tone or spasticity or mediolateral subtalar joint instability.

Question 12

What is the most common deformity at the ankle/foot complex in a stroke patient?

Answer 12

Equinovarus deformity (supination)
Although excessive dorsiflexion and valgus (pronation) can also be seen.

Question 13

What are some compensatory strategies seen in patients with equinus associated with low tone?

Answer 13

vaulting and circumduction.

Initial contact will be made with foot-flat

Question 14

What orthoses would work for a patient with equinus associated with low tone?

Answer 14

Posterior leaf spring AFO.

Articulated AFO with a plantarflexion resist or stop. This is better to prevent knee hyperextension.

Question 15

What is often seen with equinus assoicated with high tone?

Answer 15

initial contact made with the forefoot, but no dorsiflexion under body weight. The foot remains plantarflexed causing knee hyperextension at midstance.

Question 16

What orthosis should be used for hypertonic equinus control?

Answer 16

Articulated AFo with dorsiflexion stop.

Solid ankle AFO with a forefoot strap to prevent dorsiflexion.

Question 17

Hindfoot supination often combined with what?

Answer 17

the midtarsal joint.

Question 18

What orthosis should be used to control supination of the hindfoot?

Answer 18

Close-fitting pastic AFO that applies the appropriate corrective force to control both the subtalar joint and the midtarsal joint.
Inclusion of the ankle joints might be detrimental and prevent correction.

Question 19

If you want to prevent hyperextension of the knee with an AFO, what angle should the AFO be set in?

Answer 19

5-7 degrees of dorsiflexion.

Question 20

What are the indications for the use of nonarticulated AFO?

Answer 20

Poor balance, inability in stance
Inability to transfer weight onto affected leg in stance
Moderate-to-severe foot abnormality; equinous valgus or varus
Mold recurvatum or instability of the knee
improve walking speed and cadence.

Question 21

What are the indications for the use of an artciulated AFO?

Answer 21

Dorsiflexor weakness only
Presence of passive or active ROM
Control knee flexion instability only (with dorsiflexion stop)
Control recurvatum only (plantarflexion stop)
improve walking speed and cadence.

Question 22

What are the indications for using a posterior leaf spring AFO?

Answer 22

Isolated dorsiflexor weakness
No tone
NO significant mediolateral instability
No orthotic influence at the knee and hip

Question 23

What are the indications for the use of a prefabricated AFO?

Answer 23

Temporary eval.
Early mobilization needed
No tone
no mediolateral instability

Question 24

What are the benefits for providing an AFO for use in weight bearing as soon as the patient is medically stable?

Answer 24

Encourages balanced standing
Provides ankle stability
Promotes postural alignment
Maintains ROM
Supports early mobilization

Question 25

What are the indications for the use of a KAFO?

Answer 25

Poor standing balance, instability, and weight transference

Moderate-to-severe genu recurvatum uncontrolled by AFO