Orthosis Research Articles

Efficacy of Hinged Ankle–Foot Orthosis on Gait Improvement of Children with Spastic Diplegic Cerebral Palsy: A Literature Review

Purpose: The purpose is to study the effect of hinged ankle–foot orthosis (HAFO) on gait kinematics and temporospatial parameters of children with diplegic cerebral palsy. Methods: A literature search has been conducted from 2005 to 2022 to find the studies measuring the effect of HAFO on children with diplegic spastic cerebral palsy (CP) during gait through various bibliographic databases: PubMed, Scopus, EMBASE, O and P Virtual Library and Google Scholar. Results: We found 96 pieces of potentially relevant literature from which only six studies met the inclusion criteria were included. One hundred and fifty-three participants, with a mean age of 8.6 years (4–17 years), were investigated, of which 128 were spastic diplegic CP. Among spastic diplegic, 45 individuals were identified as walking with true equinus gait and 34 with jump gait. Gait parameters of participants were evaluated with ankle–foot orthoses (AFO) (hinged, solid and supramalleolar orthosis), and barefoot walking conditions showed improvement in some kinematic and spatial-temporal parameters, making their gait closer to that of typically developing children. Conclusion: HAFO was found very satisfactory, as it improves dynamic stability and ankle range of motion resulting in a more natural gait in children with spastic diplegic CP.

Model predictive control of an active ankle-foot orthosis with non-linear actuation constraints

The goal of active ankle-foot orthoses (AAFO) is to assist the user in recreating a nominal gait motion. Previously proposed control systems for AAFOs have been reactive, with controllers based on the current tracking error. However, the optimal AAFO controller must ensure adequate trajectory tracking while minimizing the amount of assistance provided to the user. To this end, a model predictive controller (MPC) can be considered to determine the optimal control sequence for a given trajectory. The MPC minimizes the control effort, thereby determining the minimal assistance required for a user to regain a natural gait. This work outlines the formulation of a non-linear MPC for an AAFO and its combination with an extended state observer (ESO) for tracking of an AAFO.In this work, a MPC controller is proposed for optimal control of an AAFO, a linear plant subject to non-linear actuation constraints. A novel method is expressed to determine the initial control horizon selection in combination with variable step Newton-based optimization to enable real-time implementation. The MPC control effort is then combined with the estimated disturbance from an ESO to accurately track the desired gait.Simulations and experimental results prove the tracking capabilities of the proposed method. Compared to a tuned proportional–derivative controller, the simulated controller reduced the trajectory tracking error by up to 65.1% and 15.3% in an undisturbed and disturbed environment, respectively. The MPC and ESO combination allows the controller to identify the optimal control action for accurate trajectory tracking. Concurrently, the ESO rejects both external and internal disturbances, with superior tracking capabilities in both undisturbed and heavily disturbed systems, making it the optimal choice for AAFO control.

A comparison of the perceptions of wearing an ankle foot orthosis by individuals with peripheral artery disease according to their baseline-level of physical activity

IntroductionPeripheral artery disease (PAD) is a prevalent cardiovascular disease that limits an individual's ability to walk. One potential way to improve physical activity for patients with PAD is an ankle foot orthosis (AFO). Previous research has found that various factors may influence an individual's willingness to wear AFOs. However, one factor that has been understudied is an individual's baseline physical activity level prior to wearing AFOs. Therefore, the purpose of this study was to compare the perceptions of wearing AFOs for 3 months among individuals with PAD according to their baseline level of physical activity. MethodsAccelerometer-derived physical activity prior to AFO prescription was used to classify participants into either a higher or lower activity group. Semi-structured interviews were conducted at 1.5 and 3-months after wearing the AFOs to assess participants’ perceptions of using the orthosis. Data were analyzed by a directed content analysis approach, then the percentage of respondents for each theme were calculated and compared between higher and lower activity groups. FindingsSeveral differences were found. Participants in the higher activity group more often reported positive impacts from wearing the AFOs. Additionally, participants who were in the lower activity group more often reported the AFOs caused physical pain while participants in the higher activity group more often reported the device was uncomfortable during daily activities. ConclusionBaseline physical activity levels may help to better understand barriers to wear and needed support to increase adherence to an AFO wear prescription, especially for patients with PAD with limited activity.

Modulation of the angle of rigid ankle-foot orthosis to control knee hyperextension in children with unilateral cerebral palsy

The aim of this study was to compare the effects of a modified 5° dorsiflexion ankle-foot orthosis (AFO) to the traditional right angle rigid AFO on controlling knee hyperextension and improving spatiotemporal gait parameters in children with unilateral cerebral palsy (CP). We used a pretest-posttest experimental design in which forty children (2-6 years) of both genders with unilateral CP were randomly assigned into two equal groups (A and B). Group A used a traditional right angle rigid AFO and received a selective exercise program to enhance walking pattern while group B used a modified 5° dorsiflexion rigid AFO and received the same exercise program as group A. Assessments for the knee angle during mid-stance and spatiotemporal gait parameters were done pre and post-intervention programs for both groups. All statistical analyses were conducted using the Statistical Package for Social Studies (SPSS) version 25 for windows (IBM SPSS, Chicago, IL, USA). There was a significant decrease in the knee angle in mid-stance post-treatment in groups A and B compared to pre-treatment (p < 0.001) but a significant increase in spatiotemporal gait parameters post-treatment in groups A and B compared to pre-treatment (p < 0.001). There was a significant decrease in the knee angle in mid-stance of group B compared to group A in post-treatment (p > 0.001). However, there was no significant difference in spatiotemporal gait parameters between groups post treatment (p > 0.05). In conclusion, using a rigid AFO improves the spatiotemporal gait parameters and decreases knee hyperextension for children with unilateral CP. Furthermore, a modified 5° dorsiflexion rigid AFO is recommended for better control of knee hyperextension than a traditional right angle rigid AFO for such cases.

"That's frustrating": Perceptions of ankle foot orthosis provision, use, and needs among people with cerebral palsy and caregivers.

Cerebral palsy (CP) affects roughly 3 per 1000 births in the United States and is the most common pediatric developmental motor disability. Ankle foot orthoses (AFOs) are commonly prescribed to provide support and improve function for individuals with CP. The study objective was to evaluate the lived experiences of individuals with CP and their caregivers regarding AFO access, use, and priorities. We examined experiences around the perceived purpose of AFOs, provision process, current barriers to use, and ideas for future AFO design. Secondary qualitative data analysis. Secondary data analysis was performed on semistructured focus groups that included 68 individuals with CP and 74 caregivers. Of the focus group participants, 66 mentioned AFOs (16 individuals with CP and 50 caregivers). Deidentified transcripts were analyzed using inductive coding, and the codes were consolidated into themes. Four themes emerged: 1) AFO provision is a confusing and lengthy process, 2) participants want more information during AFO provision, 3) AFOs are uncomfortable and difficult to use, and 4) AFOs can benefit mobility and independence. Caregivers and individuals with CP recommended ideas such as 3D printing orthoses and education for caregivers on design choices to improve AFO design and provision. Individuals with CP and their caregivers found the AFO provision process frustrating but highlight that AFOs support mobility and participation. Further opportunities exist to support function and participation of people with CP by streamlining AFO provision processes, creating educational materials, and improving AFO design for comfort and ease of use.

Development and Initial Evaluation of a Soft Ankle Support for Children With Ankle Impairments.

Develop and initially evaluate a soft ankle support (SAS) garment for children with ankle impairments. Two participants were evaluated at baseline and interviews with their parent(s) to identify wants and needs for the SAS. The SAS was developed and evaluated via participant report and functional measures in barefoot, ankle-foot orthosis (AFO), and SAS conditions. Children and parents expressed dissatisfaction with AFOs' dimensions, weight, adjustability, comfort, and ease of use. Gait and gross motor function were similar for SAS and AFOs' conditions; however, participants rated the SAS better for weight and bulk, integration with shoes, adjustability, comfort, cost, and washability. The SAS and AFOs performed similarly in this initial testing, yet the SAS also met participants' needs across key metrics not well addressed by AFOs. Ankle support devices that meet users' broad needs may support improved adherence and user satisfaction.

Halo Traction Followed by Halo Vest Immobilization for the Treatment of Chronic Atlantoaxial Rotatory Fixation: A Case Report and Tips for Avoiding Complications in Pediatric Patients.

A 4-year-old girl sustained a traumatic atlantoaxial rotatory subluxation. She presented at the treating facility 8 months after injury with cervical deformity, neck pain, gait instability, and decreased cervical motion. Her delay in presentation was partially because of international Corona Virus of 2019 (COVID-19) travel restrictions. The case was successfully treated with halo traction, followed by halo vest immobilization. Chronic atlantoaxial rotatory fixation can be treated nonsurgically with closed reduction and halo traction, but is associated with operative risks. Optimal pin placement is challenging in the pediatric skull and may be improved with a preoperative or intraoperative computed tomography (CT) scan.

Comparison of multiple 3D scanners to capture foot, ankle, and lower leg morphology.

3D scanning of the foot and ankle is gaining popularity as an alternative method to traditional plaster casting to fabricate ankle-foot orthoses (AFOs). However, comparisons between different types of 3D scanners are limited. The aim of this study was to evaluate the accuracy and speed of seven 3D scanners to capture foot, ankle, and lower leg morphology to fabricate AFOs. Repeated-measures design. The lower leg region of 10 healthy participants (mean age 27.8 years, standard deviation [SD] 9.3) was assessed with 7 different 3D scanners: Artec Eva (Eva), Structure Sensor (SS I), Structure Sensor Mark II (SS II), Sense 3D Scanner (Sense), Vorum Spectra (Spectra), Trnio 3D Scanner App on iPhone 11 (Trnio 11), and Trnio 3D Scanner App on iPhone 12 (Trnio 12). The reliability of the measurement protocol was confirmed initially. The accuracy was calculated by comparing the digital scan with clinical measures. A percentage difference of #5% was considered acceptable. Bland and Altman plots were used to show the mean bias and limit of agreement (LoA) for each 3D scanner. Speed was the time needed for 1 complete scan. The mean accuracy ranged from 6.4% (SD 10.0) to 230.8% (SD 8.4), with the SS I (21.1%, SD 6.8), SS II (21.7%, SD 7.5), and Eva (2.5%, SD 4.5) within an acceptable range. Similarly, Bland and Altman plots for Eva, SS I, and SS II showed the smallest mean bias and LoA 21.7 mm (LoA 25.8 to 9.3), 21.0 mm (LoA 210.3 to 8.3), and 0.7 mm (LoA 213 to 11.5), respectively. The mean speed of the 3D scanners ranged from 20.8 seconds (SD 8.1, SS I) to 329.6 seconds (SD 200.2, Spectra). Eva, SS I, and SS II appear to be the most accurate and fastest 3D scanners for capturing foot, ankle, and lower leg morphology, which could be used for AFO fabrication.

Content Validity of a Collaborative Goal-Setting Pictorial Tool for Children Who Wear Ankle-Foot Orthoses: A Modified Delphi Consensus Study

ABSTRACT Introduction To determine the optimum prescription and dosage for an ankle-foot orthosis and footwear, clinicians and families need to agree on goals for intervention. To facilitate family-centered collaborative goal setting, a table of potential goals and its pictorial representation had been developed previously. These tools incorporated the International Classification of Functioning, Disability, and Health (ICF) and International Organization for Standardization (ISO) clinical objectives for orthoses and were structured in an approach understandable to families. This study aimed to obtain consensus on the content validity of the Table and Pictorial Tools. Methods Seventeen experts from seven countries (orthotists, physical therapists, physicians, surgeons, and engineers) were invited. A modified Delphi technique was used to evaluate and refine the Table Tool (rounds 1 and 2) and Pictorial Tool (rounds 3 and 4). Participants rated their agreement with overall tool structure, content, and feasibility of use on a 4-point Likert scale, and provided open-ended feedback. Consensus was defined as a median score ≥3 (agree) with 75% of responses ≥3. Data were collected using REDCap. After each round, thematic analysis guided document revisions and anonymized feedback. Results Ten experts from four countries completed the study. Round 1 (Table Tool): median ratings were all 3; consensus was achieved for 3/5 questions. Round 2: full consensus was achieved. Round 3 (Pictorial Tool): median ratings were ≥3 for 10/11 questions; consensus was achieved for 4/11 questions. Round 4: full consensus was achieved. Conclusions The content validity for the Table and Pictorial Tools was established by modified Delphi consensus. These tools represent a comprehensive selection of goals across all ICF components. Clinical Relevance These novel tools have the potential to facilitate collaborative goal setting between families and clinicians and aid clinical education. A goal-setting framework specific to orthotic management may improve outcomes within the context of family-centered care.

Does use of ankle foot orthoses affect the dynamic motor control index during walking in cerebral palsy and idiopathic toe walking populations?

BackgroundThe dynamic motor control (walk-DMC) index during walking is a measure of the complexity of muscle activation pattern. Ankle Foot Orthoses (AFO) are frequently used to improve the gait of children with Cerebral Palsy (CP) and Idiopathic Toe Walking (ITW). The purpose of this study was to assess the change in walk-DMC index secondary to AFO use. Research QuestionDoes the change in walk-DMC reflect the change in walking kinematics with the use of AFO. MethodsIndividuals with diagnosis of CP or ITW with gait analysis data available for barefoot and AFO condition were retrospectively identified. For each individual, the walk-DMC index, Gait Deviation Index (GDI) and Gait Variable Scores (GVS) of knee and ankle kinematics were computed for BF and AFO conditions. Paired t-tests were used to compare key variables between BF and AFO conditions. Multi-variate stepwise regression analysis was performed to identify variables that may predict the increase in walk-DMC between BF and AFO condition. Results253 individuals were included in the study. For CP individuals (n = 208), statistically significant but quantitatively minimal improvement was observed in walk-DMC (1 ± 9), GDI (2 ± 9) and ankle GVS (2 ± 7). For ITW individuals (n = 45), larger improvements were observed in walk-DMC (11 ± 13), GDI (9 ± 11) and ankle GVS (6 ± 7).Diagnosis of ITW, use of Solid-AFO and Posterior Leaf Spring-AFO were the significant predictor of increase in walk-DMC with AFO. Higher ankle GVS at BF condition (larger deviation from TD) led to larger increase in walk-DMC. Higher knee GVS (larger deviation from TD) led to smaller increase in walk-DMC. SignificanceUse of AFO can lead to improvement in walking kinematics that is reflected in increase in walk-DMC with AFO compared to BF for ITW individuals. The change in kinematics and walk-DMC with use of AFO was minimal for CP individuals.

Functional Benefit and Orthotic Effect of Dorsiflexion-FES in Children with Hemiplegic Cerebral Palsy

Functional electrical stimulation of the ankle dorsiflexor (DF-FES) may have advantages over ankle foot orthoses (AFOs) in managing pediatric cerebral palsy (CP). This study assessed the functional benefit and orthotic effect of DF-FES in children with hemiplegic CP. We conducted an open-label prospective study on children with hemiplegic CP ≥ 6 years who used DF-FES for five months. The functional benefit was assessed by repeated motor function tests and the measurement of ankle biomechanical parameters. Kinematic and spatiotemporal parameters were assessed by gait analysis after one and five months. The orthotic effect was defined by dorsiflexion ≥ 0° with DF-FES at either the mid or terminal swing. Among 26 eligible patients, 15 (median age 8.2 years, range 6-15.6) completed the study. After five months of DF-FES use, the results on the Community Balance and Mobility Scale improved, and the distance in the Six-Minute Walk Test decreased (six-point median difference, 95% CI (1.89, 8.1), -30 m, 95% CI (-83.67, -2.6), respectively, p < 0.05) compared to baseline. No significant changes were seen in biomechanical and kinematic parameters. Twelve patients (80%) who showed an orthotic effect at the final gait analysis experienced more supported walking over time, with a trend toward slower walking. We conclude that the continuous use of DF-FES increases postural control and may cause slower but more controlled gait.

Management of perinatal cervical spine injury using custom-fabricated external orthoses: design considerations, narrative literature review, and experience from the Hospital for Sick Children. Illustrative cases.

Cervical spine injuries in neonates are rare and no guidelines are available to inform management. The most common etiology of neonatal cervical injury is birth-related trauma. Management strategies that are routine in older children and adults are not feasible due to the unique anatomy of neonates. Here, the authors present 3 cases of neonatal cervical spinal injury due to confirmed or suspected birth trauma, 2 of whom presented immediately after birth, while the other was diagnosed at 7 weeks of age. One child presented with neurological deficits due to spinal cord injury, while another had an underlying predisposition to bony injury, infantile malignant osteopetrosis. The children were treated with a custom-designed and manufactured full-body external orthoses with good clinical and radiographic outcomes. A narrative literature review further supplements this case series and highlights risk factors and the spectrum of birth-related spinal injuries reported to date. The current report highlights the importance of recognizing the rare occurrence of cervical spinal injury in newborns and provides pragmatic recommendations for management of these injuries. Custom orthoses provide an alternate option for neonates who cannot be fitted in halo vests and who would outgrow traditional casts.

Chiari I malformation management in patients with heritable connective tissue disorders

BackgroundChiari malformation type I (CMI) is relatively common neurosurgical condition typically treated with posterior fossa decompression. However, the management of CMI in patients with heritable connective tissue disorders (CTDs), such as Ehlers-Danlos Syndrome, Marfan Syndrome, or Osteogenesis Imperfecta, involves a unique set of perioperative challenges. ObjectiveThis study aims to define the demographic information, comorbidities, and perioperative course of patients with concomitant CMI and CTD. MethodsPatients with CMI admitted for surgical decompression from 2008 to 2015 were captured using the National Inpatient Sample (NIS). Information was collected based on ICD-9 codes. Descriptive and regression analyses were performed in SPSS (version 26). Results38,169 CMI patients, 353 of whom had CTD (0.92%), were identified. CMI patients with CTD were more likely to be female (p < 0.001) and present during teenage (p = 0.033) or young adult years (p < 0.001). They had more chronic issues (p < 0.001): systemic comorbidities include postural orthostatic tachycardia syndrome, cardiac dysrhythmias, and gastroparesis (all p < 0.001). CNS comorbidities include migraine, tethered spinal cord, and epilepsy (all p < 0.001). They have increased joint instability (both p < 0.001), as well as craniocervical instability (CCI). More posterior cervical fusion surgeries and application of cervical halo devices were seen during the same inpatient stay (both p < 0.001). ConclusionsPatients with concurrent CTD and CMI were more likely to present with complex Chiari and associated CCI. They were also younger, more often female, and had more systemic, CNS, and joint abnormalities. As such, preoperative recognition of an underlying CTD is imperative to achieve optimal outcomes in this patient population.

The quality of systematic reviews/meta-analyses assessing the effects of ankle-foot orthosis on clinical outcomes in stroke patients: A methodological systematic review.

Given the importance of systematic reviews (SRs) for practitioners, researchers, and policymakers, it is essential to assess them to ensure robust methodology and reliable results before applying them. The purpose of this methodological study was to assess the methodological and reporting quality of recently published SRs and/or meta-analyses(MAs) evaluating the effects of ankle-foot orthoses (AFOs) on clinical outcomes in stroke survivors. PubMed, Scopus, Web of Science, Embase, ProQuest, CENTRAL, REHABDATA, and PEDro were searched. The research team applied A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2) tool and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist for evaluating the reporting and methodological quality, respectively, and the ROBIS tool was used to evaluate the risk of bias (RoB) in the included reviews. The quality of the evidence was also judged using the (Grades of Recommendation, Assessment, Development and Evaluation) GRADEmethod. In final, 14 SRs/MAsmet inclusion criteria. Evaluation of methodological quality using the AMSTAR-2 tool demonstrated that the overall quality of included reviews was mostly "critically low"or "low,"except for two studies that were "high."In addition, the findings showed that the mean score of the reporting quality of the included reviews based on the PRISMA criteria was 24.9, down from 42. In accordance with the overall evaluation applying the ROBIS tool, 14.3% of the review studies were evaluated as high RoB, 64.3% were evaluated as unclear RoB, and 21.4% were evaluated as low RoB. Regarding the level of evidence quality, the GRADE results indicated that the evidence quality of the included reviews was unsatisfactory. This study showed that although the reporting quality of recently published SR/MAs evaluating the clinical effects of AFOs in stroke survivors was moderate, the methodological quality of almost all reviews was suboptimal. Therefore, reviewers must consider a number of criteria in designing, conducting, and reporting their studies to move towardtransparent and conclusive results.

Towards a More Inclusive Society: The Social Return on Investment (SROI) of an Innovative Ankle–Foot Orthosis for Hemiplegic Children

Hemiplegia is a form of disability that affects one side of the body and has a prevalence of 0.5–0.7 per 1000 live births. It has consequences not only at the medical level but also on psychological, cognitive, and social aspects, and it prevents children from social participation, especially in sports settings. The studies demonstrating the social impact of sports on the hemiplegic population and, in particular, children, are limited. In addition, previous evaluations of healthcare sports initiatives in the hemiplegic population are not available, and traditional methods of evaluation, which are mostly focused on economic outcomes, are not applicable. Thus, this article employs the social return on investment (SROI) methodology, which is able to determine the socio-economic impacts of an initiative, to evaluate the impact of an innovative ankle–foot orthosis (AFO) for hemiplegic children that was created to promote the possibility of “sports for all”. The model was designed with the involvement of stakeholders in all the phases and with mixed methods to assess the input, outcomes, and impact indicators. The final SROI, computed for a time horizon of three years and with a focus on the Lombardy Region, was equal to 3.265:1. Based on this result, the initiative turned out to be worthy of investment.

Effects of ankle-foot orthoses on different gait patterns in children with spastic cerebral palsy: A statistical parametric mapping study.

Ankle-foot orthoses (AFOs) are a common treatment to correct gait deviations in children with spastic cerebral palsy (SCP). Studies on the outcome of AFOs on gait often do not account for different gait patterns. The aim of this study was to investigate the effects of AFOs on specific gait patterns in children with cerebral palsy. Retrospective, unblinded, controlled, cross-over study. Twenty-seven children with SCP were assessed in the conditions walking barefoot or with shoes and AFO. AFOs were prescribed based on usual clinical practice. Gait patterns for each leg were classified as excess ankle plantarflexion in stance (equinus), excess knee extension in stance (hyperextension), or excess knee flexion in stance (crouch). Differences in spatial-temporal variables and sagittal kinematics and kinetics of the hip, knee, and ankle between the 2 conditions were determined using paired t-tests and statistical parametric mapping, respectively. The effect of AFO-footwear neutral angle on knee flexion was tested using statistical parametric mapping regression. AFO use improved spatial-temporal variables and reduced ankle power generation in preswing. For "equinus" and "hyperextension" gait patterns, AFOs decreased ankle plantarflexion in preswing and initial swing and decreased ankle power in preswing. Ankle dorsiflexion moment increased in all gait pattern groups. Knee and hip variables did not change in any of the 3 groups. AFO-footwear neutral angle had no effect on changes in sagittal knee angle. Although improvements in spatial-temporal variables were seen, gait deviations could only partially be corrected. Therefore, AFO prescriptions and design should individually address specific gait deviations and their effectiveness in children with SCP should be controlled.

Efficacy of Plantar Orthoses in Paediatric Flexible Flatfoot: A Five-Year Systematic Review

Paediatric flexible flatfoot (PFF) is a very common condition and a common concern among parents and various healthcare professionals. There is a multitude of conservative and surgical treatments, with foot orthoses (FO) being the first line of treatment due to their lack of contraindications and because the active participation of the child is not required, although the evidence supporting them is weak. It is not clear what the effect of FO is, nor when it is advisable to recommend them. PFF, if left untreated or uncorrected, could eventually cause problems in the foot itself or adjacent structures. It was necessary to update the existing information on the efficacy of FO as a conservative treatment for the reduction in signs and symptoms in patients with PFF, to know the best type of FO and the minimum time of use and to identify the diagnostic techniques most commonly used for PFF and the definition of PFF. A systematic review was carried out in the databases PubMed, EBSCO, Web of Science, Cochrane, SCOPUS and PEDro using the following strategy: randomised controlled trials (RCTs) and controlled clinical trials (CCTs) on child patients with PFF, compared to those treated with FO or not being treated, assessing the improvement of signs and symptoms of PFF. Studies in which subjects had neurological or systemic disease or had undergone surgery were excluded. Two of the authors independently assessed study quality. PRISMA guidelines were followed, and the systematic review was registered in PROSPERO: CRD42021240163. Of the 237 initial studies considered, 7 RCTs and CCTs published between 2017 and 2022 met the inclusion criteria, representing 679 participants with PFF aged 3-14 years. The interventions of the included studies differed in diagnostic criteria, types of FO and duration of treatment, among others. All articles conclude that FO are beneficial, although the results must be taken with caution due to the risk of bias of the included articles. There is evidence for the efficacy of FO as a treatment for PFF signs and symptoms. There is no treatment algorithm. There is no clear definition for PFF. There is no ideal type of FO, although all have in common the incorporation of a large internal longitudinal arch.

Congenital atlanto-occipital dislocation in a patient with Down syndrome: a case report

Down syndrome, also known as trisomy 21, is associated with congenital cervical spine abnormalities, including atlantoaxial instability with or without os odontoideum, atlanto-occipital instability, and hypoplasia of the atlas. Herein, we report a case of Down syndrome complicated by congenital atlanto-occipital dislocation. The patient presented with severe cervical myelopathy at 13 years of age after a 10-year follow-up. Radiography and computed tomography revealed os odontoideum protruding into the foramen magnum and congenital anterior atlanto-occipital dislocation. Additionally, a bifurcated internal occipital crest with a thinned central portion of the occipital bone was noted. Magnetic resonance imaging revealed kyphotic alignment of the spinal cord with severe compression at the foramen magnum level. As the neurological impairment was partially improved by halo vest immobilization, we performed in situ O-C2 fusion with an iliac autograft and decompression of the foramen magnum and posterior arch of C1. An improvement was observed immediately after surgery. Two years after surgery, radiography and computed tomography showed solid O-C2 segment fusion. The accumulation of similar cases is essential for determining the prognosis or optimal treatment for this rare congenital condition.

Carbon fiber ankle-foot orthoses in impaired populations: A systematic review.

Carbon fiber is increasingly being used in ankle-foot orthoses (AFOs). Orthotic devices and carbon fiber-containing devices have been shown to reduce pain and improve function in multiple patient populations. Although the number of publications and interest in carbon fiber AFOs is growing, a systematic evaluation of their effects is lacking. To characterize the effects of carbon fiber AFOs in impaired individuals. Qualitative systematic review. Systematic searches in PubMed, Embase, CINAHL, and Cochrane Library were completed in July 2020. The results were deduplicated, screened, and assessed for quality by independent reviewers. Articles were excluded if they had nonhuman subjects, only healthy subjects, or included active control systems, motors, or other power sources. Seventy-eight articles were included in the qualitative synthesis. Most articles were of low to moderate methodological quality. Five commonly used devices were identified: the Intrepid Dynamic Exoskeletal Orthosis, ToeOff, WalkOn, Neuro Swing, and Chignon. The devices have unique designs and are associated with specific populations. The Intrepid Dynamic Exoskeletal Orthosis was used in individuals with lower-limb trauma, the Neuro Swing and ToeOff in individuals with neurological disorders, the Chignon in individuals with hemiplegia and stroke, and the WalkOn in people with hemiplegia and cerebral palsy. Each device produced favorable outcomes in their respective populations of interest, such as increased walking speed, reduced pain, or improved balance. The mechanical characteristics and designs of carbon fiber AFOs improve outcomes in the populations in which they are most studied. Future literature should diligently report patient population, device used, and fitting procedures.

Effects of orthoses on muscle activity and synergy during gait.

An orthosis is often used in rehabilitation to improve kinetic and kinematic parameters during gait. However, whether changes in neural control depend on wearing an orthosis during gait is unclear. We measured the muscle activity and synergy of the lower limb muscles without orthosis and with two types of orthoses: ankle-foot orthosis (AFO) and knee-ankle-foot orthosis (KAFO). Muscle activity during gait was measured in 15 healthy adults, and muscle synergies were extracted using non-negative matrix factorization. The results revealed that some muscle activities were significantly different among the three conditions. Post-hoc analysis indicated differences between each condition. Knee extensor muscle activity related to the loading response was significantly increased by wearing the AFO. In the KAFO condition, hip abductor muscle activity related to weight bearing was significantly decreased, and ankle dorsiflexor muscle activity was increased to secure clearance during the swing phase. However, the number of muscle synergies and complexity of muscle synergy did not significantly change among these conditions. However, along with changes in muscle activity, the activation pattern and weightings of muscle synergies tended to change with the use of orthoses. Each muscle activity was changed by wearing the orthosis; however, the immediate mechanical constraint did not change the framework of muscle synergy.