The effectiveness of the ToeOFF® AFO in hemiplegic gait for CVA patients with flaccid ankle paralysis

背景及目的：現今腦中風患者術後之復健工作，常常使用各種不同的功能性「踝足矯具」（Ankle-Foot Orthosis, AFO）作為步態訓練及功能維持的工具，目前已有許多研究指出這類的矯具對於控制病人踝足部擺位(alignment)以及改善步態功能方面有很大的幫助；一般來說，大部份有踝足部問題的中風病人會得到醫師處方以客製化固定踝關節式踝足矯具（solid ankle AFO, SAFO）；而近來則有一種半成品類型的踝足矯具，ToeOFF AFO，可供病人做選擇。除了製造的材料有很大的不同之外，它所具有的裁切線形式（trimline）和SAFO也有很大的差異。因此，本研究假設ToeOFF AFO的特殊裁切線，可能較SAFO提供了更好的運動空間及功能，進而幫助中風病人的行走步態；故本研究將針對腦中風患者穿戴兩種踝足矯具：ToeOFF AFO以及SAFO下進行步態分析，以期藉由研究了解其功能及對腦中風患者步態改善的功效，並了解何種裁切線形式的踝足矯具對於中風病人歩態改善最有幫助。法： 本研究募集九位偏癱型腦中風患者，在下述三種情況下來回行走進行步態分析：(1)只穿著運動鞋，(2)雙腳著運動鞋並在患側穿著ToeOFF AFO，(3)雙腳著運動鞋並在患側穿著SAFO。步態分析各項資料及參數由OPTOTRAK動作分析系統以及AMTI測力板取得；並利用BodyGemTM calorimeter量取耗氧量各項參數。果：本研究結果顯示，(1) ToeOFF AFO 符合研究假設所提出的改善步態表現之行走速度、步頻、步長、提高推進力、加強與地面接觸的平順度、降低能量消耗等；(2)在有垂足問題的兩位受試者的機械能傳遞分析中顯示，ToeOFF AFO雖然提供受試者在踝關節處產生相較於只穿運動鞋以及著SAFO情況下較大的能量，但經由能量傳遞分析結果得知，此一能量並未完全有效地傳遞於個體向前推進；(3) SAFO 對於時間空間步態參數的改善較為顯著。 論：對於腦中風病人來說，使用適當的AFO以提供對缺損之功能的補充是復健工作上非常重要的課題。不同症狀的病人對於AFO的選擇會有不同，有的病人需要提供穩定性，有的病人需要藉由AFO以提供較好的推進力。本研究的結果顯示，ToeOFF AFO雖改變受試者的步態表現並且可提供受試者較高的能量，但其改變步態的方式無法給予參與研究的腦中風患者足夠的穩定性及適應； SAFO能夠提供患者較好的穩定性，因此對於步態改善的效果較為顯著。鍵詞：腦中風、步態分析、踝足部矯具、耗能分析Objective: The aim of this study was to investigate the effectiveness of the ToeOFF AFO in hemiplegic gait in CVA patients with ankle paralysis problem, and compared it with the conventional custom-made solid ankle AFO. The comparison would include biomechanical performance in spatio-temporal parameters, joint kinematics, and joint kinetic as well as the ankle-foot roll-over shape, asymmetry ratio, and push-off power in terminal stance.esign: Experimental gait analysis; Repeated measure ANOVA analysis.articipants: Nine CVA hemiplegia patients (5 males, 4 females) participated in this study. Five subjects were left and four were right involved.etting: Rehabilitation Engineering Research Center with instrumented gait laboratory. nterventions: Three conditions: shoes only (SHOE), shoes with solid ankle AFO (SAFO), and the same shoes with ToeOFF AFO (TOEOFF).ain outcome measures: Significance in spatio-temporal parameters, gait performance, asymmetry ratio, and ankle-foot roll-over shape. esults: The major finding of this study included: (1) the ToeOFF AFO was found to be consistent of the hypotheses, which improved the walking speed, cadence step length, temporal symmetry, ankle power generation, foot contact patterns, and energy cost; (2) in subjects of drop foot group, the power flow analysis showed that part of the greater power generation with the ToeOFF AFO was partially transferred to trunk as support; (3) the SAFO provided more stability resulted in improving the spatio-temporal parameters more. onclusion: For CVA patients, walk with an adequate AFO to compensate the deficit functions is a very important issue in rehabilitation work. Dissimilar configurations of AFOs provide different effectiveness for certain condition of patients. The results of this study supported that the SAFO provided better stability, and the ToeOFF AFO provided better power generation. The generated power could make use for propulsion in more stable patients. Accordingly, these findings in the present study provided as a reference to choose an adequate AFO by considering what’s the majority of the patients need? The propulsion power or the stability is.ey words: Stroke, Gait analysis, Ankle-foot orthosis, Energy consumption致謝 I要 IIbstract IVontents VIigure contents VIIIable contents IXhapter 1 Introduction - 1 -.1 Background - 1 -.2 Research motivation - 2 -.3 Literature reviews - 3 -.3.1 Hemiplegic CVA gait deviations and patterns - 3 -.3.2 Recent development of advanced AFO’s and orthotic interventions………………………………………………………………- 9 -.3.3 Initial contact and smoothness of the gait - 11 -.3.4 Push-off power in terminal stance phase of the gait - 12 -.3.5 Ankle-foot roll-over shape - 13 -.3.6 Energy consumption on pathological gait of hemiplegic CVA patients - 13 -.4 Objectives and hypotheses - 14 -hapter 2 Materials and Methods - 16 -.1 Subjects - 16 -.2 Materials - 17 -.3 Procedure - 21 -.4 Data analysis - 24 -.5 Statistical analysis - 28 -hapter 3 Results - 29 -.1 Clinical assessment - 29 -.2 Gait performance - 32 -.2.1 Spatio-temporal parameters - 32 -.2.2 Joint kinematics and kinetics - 35 -.2.3 Ankle-foot roll-over shape - 39 -.2.3 Energy expenditure - 41 -hapter 4 Discussion - 42 -.1 Effectiveness of the ToeOFF AFO on gait for CVA subjects - 42 -.2 Comparison of the ToeOFF AFO and Solid ankle AFO - 43 -.3 The Drop foot group - 46 -hapter 5 Conclusion - 55 -eferences - 57 -ppendix A - 60 -ppendix B - 63