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This study evaluates the effects of dynamic foot orthoses (DFO) on walking and balance performance in people with multiple sclerosis (MS). Sixteen ambulant subjects with MS and ten age-matched healthy control subjects were studied on initial receipt of foot orthoses and after four weeks of daily wear. Walking speed, MS Walking Scale-12 (MSWS-12) and standing balance were assessed with and without orthoses at both these times. During standing, stance width and vision were varied, and performance was quantified using the velocity of the centre of pressure (COP), body sway velocity and the mean COP position relative to the shoe. People with MS walked slower (P <0.001) and showed increased sway when standing (P <0.001). At the first assessment, the foot orthoses caused an increase in sway and a medial and posterior shift of the COP position. At repeat measurement, the DFOs continued to increase sway compared to a shoe only condition. However, MS subjects reported an improvement in the MSWS-12 (P <0.05) and, compared to the initial session, showed decreased sway when eyes were closed both with and without DFOs. Dynamic foot orthoses may increase sway and change COP position by altering foot alignment and/or plantar afferent stimulation. Improvement in body sway over time may be an overall training effect of the DFOs, as MS subjects adapt to the initial de-stabilization
Previous research has identified areas under the foot where stimulation evokes specific tonic reflexes. The term "tonic" is used because these reflex movements occur slowly, as if tonus or tension were accumulating, in contrast to the abrupt phasic response of a tendon jerk. The concept of tonic reactions has now been incorporated into the design of dynamic foot orthoses to help provide improved orthotic treatment with a better functional outcome. This article describes the background of this technique, briefly describes the manufacture of the dynamic orthosis, and outlines some of its uses.
OBJECTIVE:: The objective was to determine whether an ankle foot orthosis improves gait velocity and tasks of functional ambulation in multiple sclerosis (MS).
DESIGN:: This cross-sectional study enrolled 15 participants with diagnosis of MS, dorsiflexion and eversion weakness, and more than 3 mos of using a physician-prescribed ankle foot orthosis (AFO). Subject ambulation was evaluated (1) without an AFO and (2) with an AFO. Outcome measures were the Timed 25-Foot (T25-FW) Walk portion of the Multiple Sclerosis Functional Composite (MSFC) and the five trials (Floor, Carpet, Up and Go, Obstacles, Stairs) of the Modified Emory Functional Ambulation Profile (mEFAP).
RESULTS:: The mean timed differences on the T25-FW and the five components of the mEFAP between the AFO vs. no device trials were not statistically significant.
CONCLUSIONS:: In MS subjects with dorsiflexion and eversion weakness, no statistically significant improvement was found performing timed tasks of functional ambulation with an AFO.
Spatiotemporal and kinematic effect of peroneal nerve stimulation versus an ankle-foot orthosis in patients with multiple sclerosis: a case series.
Sheffler LR, Bailey SN, Chae J. PM R. 2009 Jul;1(7):604-11.
OBJECTIVE: To compare the effect of a surface peroneal nerve stimulator (PNS) versus an ankle-foot orthosis (AFO) on spatiotemporal and kinematic parameters of gait in patients with multiple sclerosis.
DESIGN: This was a case series design. PARTICIPANTS: Four subjects with multiple sclerosis and dorsiflexion weakness. INTERVENTION: Quantitative gait analysis with the use of (1) no device, (2) AFO, and (3) PNS as a single point-in-time assessment. OUTCOME MEASURES: Included walking speed, stride length, cadence, and double support time; kinematic parameters included peak pelvic obliquity during swing, peak contralateral hip abduction during stance, peak knee flexion and hip flexion during swing, ankle dorsiflexion at initial contact, and peak ankle internal rotation during swing.
RESULTS: One-way analysis of variance was used to compare intrasubject performance under the 3 device conditions. The PNS significantly increased ankle dorsiflexion angle at initial contact, as compared with both no device and the AFO, in 3 of the 4 subjects. However, other spatiotemporal and kinematic gait parameters were more variably affected by the device conditions.
CONCLUSIONS: With the exception of ankle dorsiflexion angle at initial contact, PNS and AFO have a variable effect on spatiotemporal and kinematic gait parameters in individual subjects with multiple sclerosis. Further studies are indicated to determine the clinical significance of intrasubject differences between device conditions
BACKGROUND: Somatosensory deficit is a common feature of MS. One method serving to combat impaired plantar sensation may be to provide enhanced sensory feedback from the sole of the foot by changing the characteristics of a shoe sole or surface. This study aimed to inspect the effect of textured insoles on gait patterns in a group of MS patients.
METHODS: 14 patients with MS and 10 healthy control subjects were recruited for this study. Plantar sensation was evaluated using Semmes-Weinstein monofilaments. Kinematic, kinetic and EMG gait data were collected for MS patients walking with flat shoes only and again with shoes and a textured insole in contact with the sole of patients' feet.
RESULTS: A reduction in plantar sensation was identified in the MS patient group compared to the control group. Wearing the textured insoles there was a significant increase in hip and knee sagittal plane excursion, maximum ankle dorsiflexion, knee flexion and in peak acceleration ground reaction force. Throughout the stance phase, EMG activity of shank muscles was typically found to increase whilst wearing the textured insoles.
DISCUSSION AND CONCLUSION: Despite some positive changes in gait patterns when wearing textured insoles, an increased foot-shank angle in terminal stance suggests that patients did not propel their swing limb through increased contribution of ankle plantarflexor muscles, perhaps favouring more proximal muscle groups. Whilst the textured insoles may alter gait patterns in MS patients, their contribution to achieving a more regular gait pattern with sufficient propulsion from ankle plantarflexors remains uncertain.
The Effect of Textured Insoles on Gait in People with Multiple Sclerosis: An Exploratory Study.
Dixon J, Gamesby H, Robinson J, Hodgson D, Hatton AL, Warnett R, Rome K, Martin D. Physiother Res Int. 2011 Oct 28.
This study aimed to investigate whether textured insoles can improve gait in people with multiple sclerosis (MS).
Previous studies have shown that footwear, including textured insoles, may improve postural stability in healthy young and older adults (Palluel et al., 2008; Hatton et al., 2009; Hatton et al., 2011), and there is some evidence to show that footwear interventions may be beneficial for people with MS (Ramdharry et al., 2006; Kelleher et al., 2010).
Forty-six people with MS (34 women), mean age (SD) 49 years (7), who reported that they were able to walk 100 m with or without resting with the use of one stick or crutch, participated in the study.
Ethical approval was granted by the Local Research Ethics Committee. Participants were randomized to one of two textured insole groups: texture A (Algeos UK Ltd, Liverpool, UK), which was used in our previous studies (Hatton et al., 2009; Hatton et al., 2011), or texture B, a commercial insole (Crocs™, Den Haag, The Netherlands). Participants conducted baseline walking tests at their preferred speed along an instrumented walkway (GAITRite) in a laboratory setting, and temporal-spatial gait parameters were extracted. Participants then wore the insoles for two weeks and returned for repeat testing.
Paired t-tests were used to evaluate changes between baseline and follow-up.
Stride length increased between baseline and follow-up in both legs in group A (left p = 0.01, right p = 0.02) and group B (left p = 0.02, right p = 0.02). Velocity and cadence did not change significantly in either group.
This finding that textured insoles can produce improvements in stride length requires further investigation. It is consistent with research on foot orthoses in MS showing an improvement in balance after four weeks of wear
Effect of textured insoles on balance and gait in people with multiple sclerosis: an exploratory trial
J. Dixon, A.L. Hatton, J. Robinson, H. Gamesby-Iyayi, D. Hodgson, K. Rome, R. Warnett, D.J. Martin Physiotherapy; Available online 23 September 2013
To investigate the immediate effects of textured insoles on balance and gait in people with multiple sclerosis (MS), and to explore any effects after 2 weeks of wear.
Within-session repeated-measures design with an exploratory follow-up period.
Hospital gait laboratory.
Forty-six individuals with MS (34 females, 12 males), with a mean (SD) age of 49 (7) years, who could walk 100 m unassisted or using one stick/crutch.
Participants were tested wearing three types of insoles in a random order: control (smooth), Texture 1 (Algeos) or Texture 2 (Crocs™). Participants were allocated at random to wear one type of textured insoles for 2 weeks, after which they were retested.
Main outcome measures
Standing balance (centre of pressure excursions and velocity) was measured with eyes open and eyes closed on a Kistler force platform. Spatio-temporal parameters of gait were measured using a GAITRite system.
The textured insoles had no significant immediate effects on balance or gait, apart from an increase in anteroposterior sway range with eyes open for Texture 2 insoles [mean difference 4.5 (95% confidence interval 0.6 to 8.4) mm]. After 2 weeks, balance was not significantly different, but both types of textured insoles showed significant effects on spatio-temporal parameters of gait, with mean stride length increases of 3.5 cm (Texture 1) and 5.3 cm (Texture 2) when wearing the insoles.
After 2 weeks of wear, there were improvements in spatio-temporal parameters of gait. However, it is unclear whether this was a placebo effect or a learning effect.
Experiences of functional electrical stimulation (FES) and ankle foot orthoses (AFOs) for foot-drop in people with multiple sclerosis.
Bulley C, Mercer TH, Hooper JE, Cowan P, Scott S, van der Linden ML. Disabil Rehabil Assist Technol. 2014 May 6.
Purpose: A constructivist phenomenological study explored impacts of ankle foot orthoses (AFOs) or functional electrical stimulation (FES) on people with foot-drop from multiple sclerosis (MS). Method: Focus groups following topic guides were analysed using interpretative phenomenological analysis, with researcher reflexivity, participant verification and peer checking of analysis. Participants with sustained use of the devices (under 2 y) were invited from two quantitative studies that (a) investigated immediate FES effects (n = 12) and (b) compared habitual use of AFO (n = 7) or FES (n = 6). Two focus groups addressed AFO (n = 4) and FES (n = 6) experiences. Results: Similar numbers of positive and negative aspects were described for AFO and FES. Both reduced fatigue, improved gait, reduced trips and falls, increased participation, and increased confidence; greater balance/stability was reported for AFOs, and increased walking distance, fitness and physical activity for FES. Barriers to both included avoiding reliance on devices and implications for shoes and clothing; a non-normal gait pattern was reported for AFO, and difficulties of application and limitations in the design of FES. However, participants felt the positives outweighed the negatives. Conclusions: Participants felt benefits outweighed the drawbacks for AFO and FES; greater understanding of user preferences and satisfaction may increase likelihood of usage and efficacy. Implications for Rehabilitation Interventions to reduce the impacts of foot-drop in people with multiple sclerosis (MS) are important to optimise physical activity participation and participation in life; they include ankle foot orthoses (AFOs) and functional electrical stimulation (FES). Research is lacking regarding user satisfaction and perceived outcomes, therefore, two separate focus groups were conducted from a constructivist phenomenological perspective to explore the impacts of AFOs (n = 4) and FES (n = 6) on people with foot-drop from MS. Some similar positive aspects of AFO and FES use were described, including reduced fatigue, improved gait and fewer trips and falls, while common barriers included finding the device cumbersome, uncomfortable, and inconvenient, with some psychological barriers to their use. On balance, the impacts of the devices on improving activities and participation were more important for participants than practical barriers, highlighting the importance of combining understanding of individual experiences and preferences with clinical decision-making when prescribing a device to manage foot-drop.