Principle of Orthosis Correction in Gait Problem

Tirza Z. Tamin

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo General Hospital,

Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Keywords: Gait Problem, Orthosis Correction, Sport Injuries

Abstract: Abnormal gait or gait abnormality occurs when the body systems are unable to aid walking in the usual

way. Gait abnormality can be caused by musculoskeletal and neuromuscular problems. It can occur among

every population from pediatric, adult and geriatric cases. If this abnormal pattern persists, it can alter the

biomechanics of the body resulting in more complications such as pain, deformity, and balance problem.

One way to facilitate the gait pattern is by using lower extremity orthosis.

1 INTRODUCTION

Gait is the reflection of how a person walks. Many

factors contribute to constructing a normal gait

pattern, such as proper body alignment,

musculoskeletal system, neuromuscular system,

also balance and proprioceptive mechanism.

Disruption to one or more of these systems will alter

how the body responds to external force, resulting in

gait abnormalities. An orthosis is one of the

conservative techniques to correct misalignment of

lower extremities to facilitate normal gait patterns.

The application of orthosis also can prevent further

deformities. This article will explain about principles

of orthosis application to facilitate normal gait

pattern in several abnormalities.

2 DISCUSSION

Treatment and management of an underlying

condition causing abnormal gait may vary. Some

injuries causing abnormal gait may require surgery

or physical therapy to help return the gait to normal.

For long-term cases of abnormal gait, a person will

likely use assistive devices for treatment. These can

include orthosis, crutches, canes, and walkers. Some

treatments cannot always correct an abnormal gait

completely, but it can at least reduce the severity of

symptoms in most cases (Standford Medicine,

2019).

General principles of orthosis correction in gait

problems are required to be known to ensure proper

prescribing of an orthosis. In correcting gait

abnormalities, orthosis was used to provide support,

stability, and maintain proper alignment to the hip,

knee and ankle joints. Some injury may also cause

deformity or malalignment which will contribute to

the development of gait problems in the future, thus

orthosis were required to prevent the deformity. The

design of orthosis prescribed must allow safe and

effective ambulation by the patient to allow maximal

functional independence. The materials used should

be light, sturdy, and resistance to wear. Prescription

of orthosis should meet the functional requirement

of the client, correlate to the patient's personality and

impact of the device upon the patient, so each client

should be evaluated individually. It is also important

to remember that in some cases orthosis is only one

component of the treatment and is not the whole

treatment for the patient.

Types of Orthosis

Orthoses are braces or splints that serve to improve

the position of a joint (positioning type) and/or

function (functional type) of an injured extremity, it

used to modify the structural and functional

characteristics of the neuromuscular and skeletal

system. Lower limb orthoses are the most commonly

prescribed type of orthoses, with Foot Orthoses

(FO), Ankle-Foot Orthoses (AFOs), Knee Orthoses

(KO), Knee-Ankle-Foot Orthoses (KAFOs) and

knee braces (Fox et al, 2019).

Foot orthoses (FO) can be helpful to correct

problems in the foot, knee, hip, and spine.

Tamin, T.

Principle of Orthosis Correction in Gait Problem.

DOI: 10.5220/0009062400620066

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 62-66

ISBN: 978-989-758-409-1

Prescription for foot orthoses are divided into two

categories as defined by the American Podiatric

Medical Association, there are (Fox et al, 2019).

1. Functional orthotics to control

abnormal motion may be used to treat foot

pain caused by abnormal motion; they can

also be used to treat injuries such as shin

splints or tendinitis. Functional orthotics

are usually crafted of a semirigid material

such as plastic or graphite.

2. Accommodative orthotics are

softer and provide additional cushioning

and support. They can be used to treat

diabetic foot ulcers, painful calluses on the

bottom of the foot, and other uncomfortable

conditions.

Two types are custom and non-custom orthoses.

Custom foot orthoses start with a thorough

examination of the foot-ankle complex to determine

limitations in range of motion in both the forefoot

and the rear foot, including calcaneal talus

alignment. Once this is done, a gait assessment is

performed without shoes and socks on. An

impression is taken using step-in foam, cast, or a

scan (with an optical digitizer) with the foot held in

subtalar neutral. Any other type of foot orthosis is

non-custom. This includes the type patients may

receive from various outlets claiming custom fit.

There are many minor foot problems for which non-

custom foot orthoses provide appropriate treatment

(Nolan et al, 2010).

Successful foot orthotic

treatment is dependent on the shoes that are used in

conjunction with the orthosis. If a person brings in a

shoe that barely accommodates his or her feet (too

tight or too worn), then placing a foot orthotic into it

will lead to failure. After fitting the patient using the

proper shoes, the orthotist reassesses the patient's

gait to determine whether goals for alignment,

posture, pain, and corrections to the foot-ankle

complex are being met. Education and follow up is

key to a successful outcome (Fox et al, 2019).

Ankle-Foot Orthoses (AFOs) are used for

problems dealing with foot and ankle issues. These

orthoses include any devices that pass across the

ankle joint but stay distal to the knee joint. This

orthosis is used for diagnoses that range from ankle

sprains to stroke management and potentially be

used for any neuromuscular condition requiring

support or assistance at the level of the foot and

ankle (Fox et al, 2019).

Figure 1. Ankle–Foot Orthosis (AFOs) (Fox et al, 2019).

A study conducted by Nolan KJ., Saalia KK. et

al (2010) in the evaluation of a dynamic ankle-foot

orthosis in hemiplegic gait showed that there was

increased hip flexion at foot strike and toe-off,

increased hip sagittal plane angular velocity during

the swing phase and decreased abduction. The

dynamic ankle-foot orthosis had a positive effect on

the participant's overall gait (Nolan et al, 2010). A

study conducted by Sankaranarayan H., Gupta A. et

al (2016) in Role of ankle-foot orthosis in improving

locomotion and functional recovery in patients with

stroke showed that ankle-foot orthosis (AFO)

improved locomotion and functional recovery after

stroke (Sankaranarayan et al, 2019).

A study

conducted by Ferreira LAB, Neto HP, et al (2013)

showed that all types of AFO (Ankle-foot Orthosis)

resulted in a significant improvement in gait velocity

compared to a control group without the use of an

AFO. There have been advances in understanding

how AFOs can enhance the patient's ability. This

includes functional electrical stimulation devices

that replace the traditional AFO with electrical

stimulation during various times in the gait cycle

(Ferreira et al, 2013).

Knee orthosis (KO) can provide stability, limits

motion, and controls the medial-lateral movement of

the knee joint. A KO is primarily used when the

ankle-foot complex is fully functional and thus a

knee–ankle– foot orthosis (KAFO) is unnecessary.

A study conducted by Jeffrey W, Sugar T. et al

(2011) showed that patients who got stroke and used

Principle of Orthosis Correction in Gait Problem

Powered Ankle Foot Orthosis (PAFO) showed

significant improvement in cadence, ankle range of

motion, and power generation capabilities. (sugar)

Indications for KO (Fox et al, 2019):

• Medial–lateral knee instability

• Post-surgery or injury

postoperative stabilization

• Support for medial collateral

ligament (MCL), anterior cruciate ligament

(ACL), and posterior cruciate ligament

(PCL) tears and stress to limit extension or

flexion

• Rotational control

• Osteoarthritis

Figure 2. Knee Orthosis tools (Fox et al, 2019).

Figure 3. Knee-Ankle-Foot Orthoses (KAFOs) (Fox et al,

2019).

Knee-Ankle-Foot Orthoses (KAFOs) provide

stability to the knee and foot when needed during the

stance phase of ambulation and knee hyperextension

control from midstance to the terminal stance phase

in the gait cycle. Clinical indications for a KAFO

include instability of the knee and ankle, quadriceps

weakness or absence, hyperextension of the knee,

varus or valgus deformity correction in children, and

paralysis of one or both legs.

Knee braces are designed to transfer load while

allowing for normal knee motion. This depends on

the amount of leverage the knee brace can provide.

Longer braces produce a greater amount of leverage;

therefore, athletes typically select the longest brace

that provides the best fit to the extremity. The

optimal position to apply the leverage depends on

the goal of the knee brace (An K et al).

Figure 4. Knee brace (An K et al)

Wedged insoles are one of the treatment options

frequently recommended for the management of

knee OA. There are two kinds of wedged insoles,

laterally wedged insole and medial wedged insole.

This orthosis is made from various materials. The

most common material is silicon rubber,

polypropylene, and ethylene-vinyl acetate. The usual

thickness of wedged insole is ¼ inch with the

density of a 40-70 durometer scale. The density of

insole is the most important consideration regarding

its effectiveness. Fisher et al (2007) suggest that the

most optimal insole density is within the range of

20% to 50%. Wedged insole application shows

reduced in external knee adduction moment.

Orthosis for Specific Gait Problem

Cerebral palsy

Cerebral palsy is one of the most common

movement abnormalities in children. In children,

gait is a prerequisite requirement for socializing and

playing. Gait abnormalities in cerebral palsy can be

caused by spasticity, abnormal motor tone, loss of

motoric control and balance disorder (Baxter et al).

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

In general, spastic motor patterns are reasonably

consistent from stride to stride and from day to day.

However, as the age growing and there’s some

intervention over the longer term, the gait pattern

will change. The most common change with age is

from a pattern of `toe walking' (because the

gastrocnemius is dominant) to a pattern of increasing

hip and knee flexion and eventually, `crouch gait'

with hip and knee flexion and ankle dorsiflexion

(Concept for the Orthotic Treatment of Gait

Problems).

Figure 5. Common gait pattern in cerebral palsy diplegic

GRAFO and SAFO are the recommended type of

AFO to be used when the GRF directed to the

anterior knee. GRAFO is more recommended for a

patient with crouch gait to reduce ankle dorsiflexion

and increase knee extension moment. GRAFO can

control or reduce ankle and subtalar movement. By

controlling joint movement more distally, it will

change the GRF and also will affect the proximal

joint using PF-KE couple principal. A ventral shell

of GRAFO will reduce or limit anterior translation

of tibia thereby reducing ankle dorsiflexion.

(10,11)

Harrington et al and Gage reported that GRAFO will

limit ankle rocker and it will increase knee extension

(Rodda et al, 2001).

Obesity with knee osteoarthritis

Common malalignment regarding osteoarthritis is

varus and valgus alignment. Knee osteoarthritis

which affected the medial compartment will result in

a varus alignment, and which affected the lateral

compartment will result in valgus alignment.

Malalignment will cause GRF response to muscle

activation and the moment. These changes will alter

the normal gait pattern.

Patients with medial knee osteoarthritis and

varus malalignment of the knee are subject to high

overload and high angles of dynamic varus in the

knee. In these individuals, there is a pattern of gait in

external rotation with a reduction of velocity as

adaptive factors, yet insufficient to reduce weight-

bearing to normal values.

The highest flexor moment presented

demonstrates another adaptive mechanism which is

to transfer weight bearing from the frontal plane to

the sagittal plane. Individuals with medial knee

osteoarthritis have less flexion-extension variation,

which characterizes with a predominance of flexion.

Patients with knee OA demonstrate changes in gait

patterns such as increased toeing-out, reduction in

gait speed, and lateral sway of the trunk in the stance

leg.

In mild to moderate knee osteoarthritis, lateral

wedged insole (LWI) is one of the nonoperative

realignment strategies for medial compartment knee

OA. Several studies reported that LWI will displace

vector of GRF from the center of plantar pedis more

laterally to reduce medial compartment knee

loading. The force that applied on the knee started

from the center of pressure on plantar pedis. This

force will be transferred superiorly towards the knee.

A recent study shows that LWI will reduce external

knee adduction moments.

Knee unloader braces with valgus adjustment are

a mechanical intervention designed to reduce pain,

improve physical function, and possibly slow

disease progression. Pain relief is thought to be

mediated by distracting the involved compartment

via external valgus forces applied to the knee. In so

doing, tibiofemoral alignment is improved, and load

is shifted off the degenerative compartment, where

exposure to potentially damaging and provocative

mechanical stresses are reduced.

Figure 6. Knee unloader braces with valgus adjustment

Principle of Orthosis Correction in Gait Problem

Knee unloader braces with valgus adjustment are

effective in mediating pain relief caused by knee

osteoarthritis and malalignment, bracing should be

fully used before joint realignment or replacement

surgery is considered. Knee unloader braces with

valgus adjustment are reported to be a safe and

inexpensive treatment that mediates pain relief and

ameliorates function for patients with knee OA.

3 CONCLUSIONS

The orthosis is an externally applied device used to

modify the structural and functional characteristics

of the neuromuscular and skeletal system. The

orthosis can improve the quality of life of patients, it

showed that they can do activity daily living

properly especially in gait problems.

REFERENCES

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Sankaranarayan H, Gupta A, Khanna M, Taly AB,

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Ferreira LAB, Neto HP, Grecco LA, Et.al. Effect of

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KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association