Disability and Rehabilitation: Assistive Technology, 2012; Early Online: 1–13

© 2012 Informa UK, Ltd.

ISSN 1748-3107 print/ISSN 1748-3115 online
DOI: 10.3109/17483107.2012.680940

Review Article

 nkle-foot orthotic management in neuromuscular disorders:

A
recommendations for future research

Amanda E. Chisholm1,2 & Stephen D. Perry1,2,3

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1
Toronto Rehabilitation Institute, Toronto, Ontario, Canada, 2Graduate Department of Rehabilitation Science, University
of Toronto, Toronto, Ontario, Canada, and 3Department of Kinesiology and Physical Education, Wilfrid Laurier University,
Waterloo, Ontario, Canada

Purpose: To describe research evidence supporting clinical Implications for Rehabilitation

recommendations for ankle-foot orthotic (AFO) prescription
and examine common limitations in current research among
individuals with stroke and cerebral palsy. Method: Three
databases and one journal website were searched for articles
reporting AFO interventions on gait and functional mobility
For personal use only.
• Research reports need to provide clinical measures of
impairment and function to facilitate understanding
the AFO’s mechanical effect during gait.
• Standardized outcome measures related to the pre-

outcome measures in participants with stroke or cerebral palsy.
The International Society for Prosthetics and Orthotics (ISPO)
best practice recommendations from consensus conferences
were reviewed. Data extracted from the articles include
participant characteristics, AFO intervention details, evaluation
methods, and outcome measures. Results: Sixty articles were
included; twenty-seven on stroke and thirty-three on cerebral
palsy participants. Many articles reported insufficient detail
on severity of lower limb impairment. Type of interventions
included nineteen nonarticulating AFO studies, twelve
articulating AFO studies and twenty-three studies testing
both. Confounding factors, such as compliance, activity level
and footwear, need to be considered in longitudinal studies.
Conclusions: Most studies demonstrated improvement in
walking speed and ankle dorsiflexion, whereas the indirect
effect on knee stability remains unclear. Future research needs
to provide detailed information on type and severity of lower
limb impairment of participants and design features of the AFO
intervention.
Keywords:  AFO, stroke, cerebral palsy, gait
Introduction
Individuals with neuromuscular disorders often have residual
deficits and require interventions that aim to improve gait
and mobility. Improvement of walking ability is the most fre-
quently stated rehabilitation goal by individuals with mobility
scription goals and patient’s functional mobility is
essential to determine whehter the orthotic effect is
beneficial.
• ISPO recommendations should be consulted for
reporting orthotic design characteristics.
limitations [1]. Mobility aids, such as canes, wheeled walkers,
and orthotics, are commonly utilized to achieve independent
walking and perform activities of daily living.
Orthotics are included in rehabilitation plans to improve
function by adjusting joint deformities, optimizing structural
alignment, providing support, and assisting motion at a joint
[2]. Ankle-foot orthotics (AFO) are often recommended to
minimize gait dysfunction caused by abnormal muscle tone
or weakness. Previous research has found that at discharge
from hospital inpatient rehabilitation, ~22% of stroke sur-
vivors required an AFO [3]. Similarly in the cerebral palsy
(CP) population, AFOs have remained a standard treatment
for equinus contractures [4]. Despite the frequency of their
use, current clinical recommendations for orthotic manage-
ment are vague in terms of who should receive a prescription
and what type of AFO to prescribe. These recommendations
are primary based on clinical expertise and often lack support
from scientific evidence [5].
Generally, AFOs function to prevent an equinus varus
position at the ankle during the swing phase and promote

Correspondence: Amanda E. Chisholm, Mobility Team Research – Room 11–111, Toronto Rehabilitation Institute, 550 University Ave, Toronto,
Ontario M5G 2A2, Canada. Tel: 416–597-3422 ext.7828. E-mail: amanda.chisholm@utoronto.ca
(Accepted March 2012)

1
 2  A. E. Chisholm & S. D. Perry
heel strike at initial contact. As well, it has been suggested
that AFOs which prevent plantarflexion during stance may be
used to indirectly control knee hyperextension in mid-stance
via manipulation of external moments created by the ground
reaction force vector [6,7]. Other AFO types (i.e., dynamic or
posterior leaf spring) focus on energy return systems intended
to improve terminal stance by allowing ankle dorsiflexion in
mid-stance and absorbing energy like a spring to improve
push-off [8].
Previous research has focused on short-term effects of
AFOs on measures of walking ability (i.e., spatial-temporal
parameters, joint kinematics, and kinetics), and impairment
(i.e., motor control, strength, and spasticity). A review by
Leung & Moseley found variable outcomes across studies for
commonly reported gait parameters; velocity, stride length,
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and cadence [9]. Although many papers demonstrated posi-
tive effects for adults with hemiplegic gait; the efficacy for
improved walking function and mobility remains inconclu-
sive [9]. Several factors have contributed to this variability
including heterogeneous patient populations, various AFO
designs and different assessment methods. The positive results
suggest that orthotics are beneficial in particular cases and
highlight the need for more specific investigation of patient’s
clinical characteristics and type of AFO prescription.
The purpose of this review paper is to (i) describe research
evidence supporting clinical recommendations for AFO
prescription and (ii) examine common limitations in AFO
For personal use only.
research methodology for individuals with neuromuscular
disorders in respect to gait and functional mobility. A review
of previous research and current international recommenda-
tions for two clinical populations, stroke and cerebral palsy,
will help organize common issues and limitations to orthot-
ics research. Recommendations will focus on developing a
research approach for evaluating AFO prescriptions in neuro-
muscular populations to better inform clinical practice.
Literature search methods
A comprehensive literature search of articles were sought
from the following databases: Ovid-Medline (1996–2009),
EMBASE (1980–2009), and PubMed. The search was per-
formed using the following keywords; stroke, cerebral palsy,
hemiplegia, AFO, orthotic, and orthosis. Further searches
were performed on the websites of the Prosthetics and
Orthotic International journal and the International Society
of Prosthetics and Orthotics (ISPO) using similar keywords.
The ISPO has developed best practice recommendations
for orthotic prescription during a consensus conference for
stroke (Table I).
An orthotic is defined as “an externally applied device
used to modify the structural or functional characteristics of
the neuromusculoskeletal system” [5]. All articles retrieved
from the search were compared against our inclusion and
exclusion criteria. Studies were included if they evaluated an
outcome measure of gait and functional mobility relating to
AFO use among individuals who had a primary diagnosis
of stroke or cerebral palsy. Excluded were studies evaluating
the use of functional electrical stimulation or hybrid systems,
Disability and Rehabilitation: Assistive Technology
Table I. Clinical indications for AFO prescription from ISPO consensus
conference [5].
Type Indication
Nonarticulated Poor balance, instability in stance
AFO Inability to transfer weight onto affected leg in
stance
Moderate to severe foot abnormality; equinus,
valgus or varus, or a combination
Moderate to severe hypertonicity
As above, but with mild recurvatum or instability
of the knee
To improve walking speed and cadence
Articulated AFO Dorsiflexor weakness only
Where passive or active range of dorsiflexion is
present
Where dorsiflexion is needed for sit-to-stand or
stair climbing
To control knee flexion instability only,
articulated AFO with dorsiflexion stop
To control recurvatum only, articulated AFO with
plantarflexion stop
To improve walking speed and cadence
Posterior spring Isolated dorsiflexors weakness
leaf No significant problem with tone
No significant mediolateral instability
No need for orthotic influence on the knee or hip
AFO, ankle-foot orthotic; ISPO, International Society of Prosthetics and Orthotics.
robotic-assisted or active controlled orthotics, shoe lifts,
slings, casting, and taping. Only full original papers and case
studies from peer reviewed journals which were published
in English were included. The literature search found over
600 articles. After the selection criteria were applied, a total
of 60 articles (27 stroke and 33 cerebral palsy) were included
in the analysis. These articles should provide a good indica-
tion of the research developed in the field of orthotics over
the past few decades. The following data were extracted from
the selected studies; participants, AFO intervention, research
methods, and outcome measures.
Results
Participant characteristics
Orthotics research on stroke survivors usually involves
patients in the chronic phase; greater than 3 months post-
stroke (Table II). The mean time post-stroke ranged from
0.7–98 months. The mean age across the studies ranged from
38 to 66 years. Participants were able to walk independently
with or without assistive devices in a laboratory setting [6,10–
35]. Other characteristics to describe the impairment severity
included joint range of motion (ROM) [6,32,33,35], indexes
of motor control or functional limitations [10–12,14,15,21–
26,29,30,34,35] and the presence of lower limb spasticity
[12,14,18–21,23,24,29,32,34,35]. A few studies included indi-
viduals who are habitual AFO users, whereas other studies
excluded these individuals to remove possible training effects.
Orthotics research on children with CP is generally sepa-
rated into different classifications based on type and distri-
bution of motor impairment, such as spastic hemiplegia or
diplegia [7,8,36–66] (Table III). Typically, these patients
are able to walk independently in the community and have
 AFO management in neuromuscular disorders  3

Table II. Study design and description of stroke participants..

Impairment level
Author Year N Design Age Time SP PROM MOTOR
Mojica et al. 1988 8 Cross-sect (46–66) 4.8 BRS 2-3
Beckerman et al. 1996 60 RCT 58.0* 34.0*
Hesse et al. 1996 19 Cross-sect 55.2 5.1 MAS 3-5
Hesse et al. 1999 21 Cross-sect 58.2 4.9 MAS 3-5
Tyson et al. 2001 25 Cross-sect 49.9 8.3
Iwata et al. 2003 18 Longitudinal 61.8 31.0 MAS 1-3 BRS 3-5
Gok et al. 2003 12 Cross-sect 54.0 2.2 MAS 2-3
Churchill et al. 2003 5 Cross-sect 38.6 NA
Franceschini et al. 2003 9 Cross-sect 66.5 (2-244)
Danielsson et al. 2004 10 Cross-sect 52.1 23.2 MAS 2-4 FMA 16–23
de Wit et al. 2004 20 Cross-sect 61.1 26.9 MI 53 & 59.5*
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Yokoyama et al. 2005 2 Case study 40’s** 18.0 DF 0 BRS 3-4

Sheffler et al. 2006 14 Cross-sect 56.7 30.8
Wang et al. 2007 58 Cross-sect 60.4 3.3 FMA 17–32
Fatone et al. 2007 13 Cross-sect 51.5 98.4 DF 5-25
Rao et al. 2008 40 Cross-sect 63.3 0.7/50.8 MAS <2
Bleyenheuft et al. 2008 10 Cross-sect 49.0 28.0 TAR 1.5 SIAS 38–66
Abe et al. 2009 16 Cross-sect 56.0 31.1 DF 0-20 BRS 3–4
Simons et al. 2009 20 Cross-sect 57.2 39.3 MI-Leg 14–91
Fatone et al. 2009 21 Cross-sect 53.2 91.2
Nolan et al. 2010 1 Case study 42.0 11
Dogan 2010 51 Cross-sect 60.7 2.3 BI 21–85
Chen et al. 2010 14 Cross-sect 56.4 2.4 MAS 1+–3 BRS 3-5
For personal use only.

Mulroy et al. 2010 30 Cross-sect 58.3 25.3 MAS 1.5* DF 0-5/PF 10–15
Jagadamma et al. 2010 1 Case study NA 15 DF 0
Ohata et al. 2011 11 Cross-sect 52.1 20* n = 8 MAS <2 n = 9 DF >15 BRS 3–6
Hung et al. 2011 52 Cross-sect 54.5* 33.5* MAS 1+–2
TIME refers to time post-stroke in months. SP, spasticity to list of abbreviations, reported as hemiplegic (H) or diplegic (D). Spasticity refers to a measure of lower limb spasticity.
Motor refers to a measure of lower limb motor control. Age and time post-stroke is reported as a mean score or range as indicated by brackets.
BI, Barthel index; BRS, Brunnstrom recovery stage; Cross-retro, cross-sectional retrospective; Cross-sect: cross-sectional; DF, ankle dorsiflexion; FMA, Fugl–Meyer motor assess-
ment—leg; GMFCS, Gross Motor Functional Classification System; MAS, Modified Ashworth Scale—ankle plantarflexors; MI, motricity index; PF, ankle plantarflexion; PROM,
passive dorsiflexion range of motion; RCT, randomized controlled trial; SIAS, stroke impairment assessment set.
*Studies reported a median score. **Yokoyama et al. indicated the both study participants were in their 40’s.

previously used lower limb orthotics. Most studies eliminate
participants with severe motor impairments and mobility
restrictions that require other assistive technologies for ambu-
lation. Individuals with severe joint deformity who recently
participated in pharmacological (i.e., phenols or botulinum
toxin-A) and/or surgical (i.e., dorsal rhizotomy) treatments
are eliminated to remove possible confounding effects. The
mean age of participants ranged from 4 to 9 years. Similar to
stroke, patients are usually described in the selection criteria
by lower limb ROM and presence of any fixed contractures.
The ISPO clinical recommendations for cerebral palsy
stated that the minimum detail on participants should include
age, gender, type and distribution of cerebral palsy, Gross
Motor Functional Classification System (GMFCS) level, and
any recent surgery or pharmacological intervention [67].
Additionally, research involving AFOs should describe ROM
of all lower extremity joints, specifically ankle dorsiflexion
with knee extended, any fixed deformities, muscle spasticity,
and strength [67]. GMFCS scores were not frequently stated;
only eight studies reported scores ranging from 1 to 3,
indicating mild to moderately impaired gross motor function.
Other characteristics were reported less frequently; seven
studies reported severity of spasticity [7,50,54,56,57,59,61]
and six studies provided some resting lower limb ROM data
[41–43,48,54,57], whereas other studies used ROM measures
in their selection criteria[7,56,59]. Romkes and coauthors
reported that participants had either a type 1 or 2 gait pattern
based on Winters et al. classification system, while another
study by Smith and coauthors only included patients with a
jump gait pattern [59,60].
AFO intervention
Tables IV and V provides a description of the AFO designs
utilized in each study. Thirteen studies described the goal of
examining their specific AFO design [7,8,16,24,28,31,35,36,
44,46,53,56,59]. The type of AFO device was stated by most
studies (54/61). Nineteen studies used nonarticulating AFOs
(11 stroke and 8 CP), twelve studies tested articulating AFOs
(7 stroke and 5 CP), and twenty-two studies had both types
(4 stroke and 18 CP). Thirty-three studies provided complete
or partial information on material type and thickness. Some
studies provided a description of the foot plate length (33/61),

© 2012 Informa UK, Ltd.

 4  A. E. Chisholm & S. D. Perry

Table III. Study design and description of cerebral palsy participants.

Impairment level
Author Year N Design Age Type SP PROM Motor
Middleton et al. 1988 1 Case study 4.5 D Moderate DF 5
Hainsworth et al. 1997 12 Longitudinal 4.7 H/D DF 5
Carlson et al. 1997 11 Longitudinal 6.9 D
Radtka et al. 1997 10 Cross-sect 6.5 H/D MAS 1-2 DF 5
Abel et al. 1998 35 Cross-sect 8.7 D DF 0
Brunner et al. 1998 14 Cross-sect 11.4* H
Rethlefsen et al. 1999 21 Cross-sect 9.1 D MAS 0-4 DF 2-18
Crenshaw et al. 2000 8 Cross-sect 8.4 D DF 0
Suzuki et al. 2000 6 Cross-sect 13.2 D Moderate
Buckon et al. 2001 30 Longitudinal 9.3 H DF 5 ± 6
Maltais et al. 2001 10 Cross-sect 9.0 D GMFCS 1-2
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Dursen et al. 2002 24 Cross-sect 6.7 H/D DF 5

Romkes et al. 2002 12 Cross-sect 11.9 H
Thomas et al. 2002 19 Longitudinal 9.0 H
White et al. 2002 115 Cross-retro 9.0 H/D GMFCS 1-3
Thompson et al. 2002 18 Cross-sect 8.4 H
Kott et al. 2002 28 Cross-sect 10.6 H/D GMFCS 1-2
Smiley et al. 2002 14 Cross-sect 10.7 D
Buckon et al. 2004 16 Longitudinal 8.3 D DF 8 ± 5 GMFCS 1-2
Hassani et al. 2004 16 Longitudinal 7.5 D
Park et al. 2004 19 Cross-sect 3.8 D
Radtka et al. 2005 12 Longitudinal 7.5 D MAS 1 DF 5
Lam et al. 2005 13 Cross-sect 5.9 D MAS 1-3
For personal use only.

Bjornson et al. 2006 23 Cross-sect 4.3 D GMFCS 1-3

Romkes et al. 2006 10 Cross-sect 9.7 H MAS 2-3 PF 10–DF 10
Desloovere et al. 2006 15 Cross-sect 5.9 H
Balaban et al. 2007 11 Cross-sect 7.2 H
Butler et al. 2007 21 Cross-retro 7.1 H/D PF 20–DF 20
Lucareli et al. 2007 71 Cross-retro 12.2 D
Hayek et al. 2007 56 Cross-retro 8.9 H/D GMFCS 1-2
Brehm et al. 2008 172 Cross-sect 9.0 H/D
Van Gestel et al. 2008 36 Cross-retro 8.4 H GMFCS 1-2
Smith et al. 2009 15 Longitudinal 10.6 D GMFCS 1
SP, spasticity to list of abbreviations. TYPE refers to type of involvement for the cerebral palsy population, reported as hemiplegic (H) or diplegic (D).
Cross-retro, cross-sectional retrospective; Cross-sect: cross-sectional; DF, ankle dorsiflexion; GMFCS, Gross Motor Functional Classification System; MAS, Modified Ashworth
Scale—ankle plantarflexors; PF, ankle plantarflexion; PROM, passive dorsiflexion range of motion.
*Study reported a median score.

trim lines (24/61), joint type (15/34), and motion permitted
(27/61).
Many studies (24/61) have compared the effects of two
or more different orthotics, usually to determine the supe-
riority of one over another [7,8,18,24,29,32,34,39–42,44–
46,49,50,54,56–58,60,63,64,66].
Previous AFO research demonstrated that design
changes to trim lines and joint position can alter their stiff-
ness, which may be beneficial to achieve a desired outcome
[68]. Fatone and coauthors reported that altering foot plate
length and ankle alignment separately in a hinged poly-
propylene AFO had little effect on ankle and knee angles
throughout the gait cycle [16]. The clinical significance of
subtle differences in some design features remains unclear
and requires further work for clinicians to utilize this infor-
mation in practice.
Evidence of clinical recommendations
Prescription recommendations are primarily based on best
practice points of leading researchers, physicians, orthotists
and clinicians in the field (Table I). ISPO recommendations
for stroke survivors provided some clinical indications for dif-
ferent types of orthotic devices [5], while recommendations for
CP only reviewed the pooled effects of AFOs on various gait
parameters [67].
Nonarticulated AFOs are constructed from a single piece
with trim lines usually anterior to the ankle malleoli and the
amount of flexibility depends on material type and thickness,
and height of the calf piece. Among the articles reviewed,
forty-two studies (sixteen stroke and twenty-six CP), tested
different types of non-articulating AFOs (i.e., solid, dynamic
and supramalleolar; Tables IV and V). Studies that included
stroke survivors with moderate plantarflexors spasticity

Disability and Rehabilitation: Assistive Technology

 AFO management in neuromuscular disorders  5

Table IV. Cerebral palsy study details of the AFO interventions.

AFO Intervention
Author Year CON Type Material ROM Angle Length Joint Trim
Middleton et al. 1988 SH M Plastic DF 5-35 DF 5 Full Ortholen ANT
Hainsworth et al. 1997 M No PF
Carlson et al. 1997 SH NA
Radtka et al. 1997 BF NA Plastic Full ANT
Abel et al. 1998 BF NA Plastic Mild DF ANT
Brunner et al. 1998 BF M Plastic No PF/DF 5-10 DF 0
Rethlefsen et al. 1999 SH M No PF DF 0-3 Gillette
Crenshaw et al. 2000 SH M Plastic DF 0 Full ANT/
POST
Suzuki et al. 2000
Buckon et al. 2001 BF M Plastic No PF DF 0 Full Tamarak ANT/
POST
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Maltais et al. 2001 SH A PF 0-10/DF*

Dursen et al. 2002 BF
Romkes et al. 2002 BF M No PF/free DF Full ANT/
POST
Thomas et al. 2002 BF M No PF/DF* Tamarack ANT/
POST
White et al. 2002 BF M Plastic No PF/DF* Full Tamarack ANT
Thompson et al. 2002 BF NA Plastic Mild DF MP
Kott et al. 2002 M
Smiley et al. 2002 SH M
Buckon et al. 2004 BF M Plastic No PF DF 0 Full Tamarack ANT/
POST
For personal use only.

Hassani et al. 2004 BF M Plastic No PF ANT

Park et al. 2004 BF A No PF/free DF Full ANT
Radtka et al. 2005 BF M Plastic No PF/DF* DF 0 Full Gillette ANT
Lam et al. 2005 BF NA Plastic DF 0 Full ANT
Bjornson et al. 2006 SH NA Plastic Free DF & PF Full Dynamic ANT
Romkes et al. 2006 BF A No PF/DF 20 DF 0 Full POST
Desloovere et al. 2006 BF/SH M Carbon Full Ossur spring POST
Balaban et al. 2007 BF A No PF Full ANT
Butler et al. 2007 BF NA Full
Lucareli et al. 2007 BF A
Hayek et al. 2007 BF M
Brehm et al. 2008 BF NA No PF ANT/
POST
Van Gestel et al. 2008 BF M Carbon/Plastic DF 0-10 Full Ossur spring POST
Smith et al. 2009 BF M Plastic No PF/Free DF DF 0 Gillette
A, articulated; angle, alignment angle; ANT, anterior; AFO, ankle-foot orthotic; BF, barefoot; CON, control condition; DF, ankle dorsiflexion; Joint, joint type; Length, foot plate
length; M, mixed (nonarticulated and articulated); NA, nonarticulated; PF, ankle plantarflexion; POST, posterior; ROM, range of motion permitted; SH, shoes; Trim; trim lines
relative to ankle malleoli.
*Amount of dorsiflexion varies depending on the type of AFO. **Studies that provided various changes to knee joint kinematics and kinetics.

and found improved ankle dorsiflexion during the stance
and swing phase with a solid AFO [18,29]. CP patients with
equinus using a solid AFO displayed reduced ankle ROM
[36,41,42,44,50], improved ankle position at initial con-
tact [7,36,41,42,44,50], decreased maximum plantarflexion
[7,36,50] and improved terminal stance ankle moment [7,44].
Results for dynamic AFOs include improved ankle position at
initial contact, reduced maximum plantarflexion [50,58] and
improved terminal stance ankle moment [50]. Indirect effects
on knee stability are less clear; Abel et al. reported improve
knee ROM due to increased flexion in swing with a solid AFO
[36], and Lam et al. found excessive knee flexion at initial
contact with a dynamic AFO [50], while other studies stated
no changes at the knee joint [7,41,42,58]. Some evidence may
suggest that AFOs improve stability in stance and weight
transfer, such as reduced double support time and increased
single stance time [36]. The research supports the use of non-
articulated AFOs for improving ankle dorsiflexion through-
out the gait cycle among patients with ankle plantarflexor
spasticity; however further work is required to confirm or
refute the indirect effects on knee instability.
Posterior leaf spring designs have posterior trim lines
relative to the ankle malleoli that allows dorsiflexion in mid-
stance and assist with push-off in terminal stance. Thirteen

© 2012 Informa UK, Ltd.

 6  A. E. Chisholm & S. D. Perry

Table V. Stroke study details of the AFO interventions.

AFO intervention
Author Year CON Type Material ROM Angle Length Joint Trim
Mojica et al. 1988 BF Full
Beckerman et al. 1996 AFO** NA Plastic No PF DF 5
Hesse et al. 1996 BF/SH NA Metal No PF/DF 10 DF 0 Full DF spring
Hesse et al. 1999 BF NA Metal No PF/DF 10 DF 0 Full DF spring
Tyson et al. 2001 SH A Plastic/metal No PF Full ANT
Iwata et al. 2003 AFO** NA Full POST
Gok et al. 2003 BF NA Plastic/metal DF 0 Full Seattle-type
Churchill et al. 2003 BF/SH
Franceschini et al. 2003
Danielsson et al. 2004 NA Carbon Full
de Wit et al. 2004 SH NA
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Yokoyama et al. 2005 AFO** A Plastic DF* DF 0-5 Full Oil damper
Sheffler et al. 2006 M
Wang et al. 2007 NA DF 0 POST
Fatone et al. 2007 SH A Plastic No PF DF 0 Full Tamarak
Rao et al. 2008 SH Plastic
Bleyenheuft et al. 2008 SH A Carbon Full Chignon®
Abe et al. 2009 BF M No PF/DF* Gillette/
Tamarack
Simons et al. 2009 SH M Plastic/metal Full Otto Bock
Fatone et al. 2009 SH A Plastic No PF DF 0 Full or 3/4 Tamarak
Nolan et al. 2010 NA Carbon Full
Dogan 2010 SH A No PF
For personal use only.

Chen et al. 2010 BF NA Plastic DF 0 Full/ANT ANT/POST

Mulroy et al. 2010 SH M Plastic No PF/DF* DF 5 Full Oklahoma
Jagadamma et al. 2010 AFO Plastic DF 0
Ohata et al. 2011 AFO A Metal No PF Full Oil damper
Hung et al. 2011 SH NA Plastic ANT
A, articulated; angle, alignment angle; ANT, anterior; AFO, ankle-foot orthotic; BF, barefoot; CON, control condition; DF, ankle dorsiflexion; Joint, joint type; Length, foot plate
length; M, mixed (nonarticulated and articulated); NA, nonarticulated; PF, ankle plantarflexion; POST, posterior; ROM, range of motion permitted; SH, shoes; Trim; trim lines
relative to ankle malleoli.
*Amount of dorsiflexion varies depending on the type of AFO. **Studies by Beckerman et al., Iwata et al., and Yokoyama et al. used a “placebo” AFO or modifications to the AFO
tested as the control condition.

studies examined a posterior leaf spring design, six stroke and
seven CP, on individuals who could walk independently with-
out assistive devices and did not specify if the participants
had isolated ankle dorsiflexors weakness [8,10,25,26,29,32
,39,41,42,46,63,64]. The results varied for peak ankle dorsi-
flexion during mid-stance and reduced power generation was
observed at terminal stance by restricting ankle plantarflexion
[8,41,42]. Therefore, the posterior leaf spring design may not
improve terminal stance and the amount of ankle dorsiflexion
in mid-stance may be linked to other lower limb impairments
controlling forward progression.
Articulated AFOs include devices with a hinge or pivot con-
nection that allow various degrees of ROM and/or assist motion
with a spring mechanism. Thirty-four studies tested a hinged
AFO design; eleven stroke and twenty-three CP (Tables IV and
V). Evidence indicates that hinged AFOs with a plantarflexion
stop improve ankle dorsiflexion during stance and swing phases
relative to gait in stroke and CP patients. Many studies also
reported increased ankle plantarflexion moment and reduce
ankle power generation at terminal stance [7,16,41,42,60].
During stair locomotion, a hinged AFO increased ankle dor-
siflexion in stance greater than the nonarticulating solid AFO
and no AFO conditions [63]. However, there was no differ-
ence between all AFO configurations and barefoot for velocity
and single limb stance percentage for stair ascent and descent
[63]. Participant’s passive/active ankle ROM and dorsiflexion
strength was not commonly reported and marked plantarflexor
spasticity was stated in a few studies contraindicating the rec-
ommended indications [19,20,24,54,58]. In regards to indi-
rect effects on the knee joint, two studies found no change
in knee motion throughout stance and swing in diplegic CP
patients with a hinged AFO [7,41]. The results for hemiplegic
CP patients using a hinged AFO with a plantarflexion stop are
mixed; Romkes et al. found no change in knee flexion at initial
contact and increased peak knee flexion in swing [58], while
Balaban et al. reported a decrease in knee flexion at initial
contact and no change in knee flexion during the swing phase
[37]. One study noted reduced knee extension during stance in
CP patients who displayed knee hyperextension with no AFO
[42], while two other studies found no change in peak knee
extension in stance [37,58]. Similarly, Fatone et al. reported
reduced knee hyperextension and a tendency to delay onset of
hyperextension in stance using a hinged AFO only in stroke
patients who displayed hyperextension during stance without

Disability and Rehabilitation: Assistive Technology


an AFO [16]. The evidence appears to partially support the
criteria; however future work still needs to address the inter-
action with lower limb spasticity and indirect effects at the
knee joint.
Research methods
Most research studies are cross-sectional case control designs
testing short-term outcomes of AFO interventions (Tables
II and III). Only one randomized controlled trial was found
demonstrating the lack of high quality evidence in orthotics
research [11]. This study reported no beneficial effects with
using an AFO for 12 weeks on walking ability, defined as gait
velocity, in chronic stroke survivors. These results should
be considered carefully since velocity does not represent all
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aspects of walking ability and may be influenced by other
underlying impairments. Additionally, many complaints
were reported in regards to the AFO fit; thus only 50% of
participants complied with wearing the AFO [11]. In the CP
literature, nine longitudinal studies have reported various
beneficial effects, such as improved ankle kinematics and
kinetics throughout the gait cycle [7,41,42,44,48,49,58,60,63].
Many of these studies reported increased step or stride length
along with mixed results for cadence and walking speed with
AFO use. Other studies included four case reports and four
retrospective cohort designs [24,32,33,43,52,54,62,66].
Since few studies have examined the long-term effects of
For personal use only.
AFO interventions on gait performance, the optimal amount
of practise time for adaptation remains unknown. This infor-
mation is essential for clinicians to give instructions to their
patients and set up a review schedule. The amount of practise
time varied considerably in the studies reviewed. Participants
involved in cross-sectional studies either currently used an
AFO or were allowed a short period of practise time on the
day of testing. Among the longitudinal studies the interven-
tion period varied; 1–3 months for stroke [11,21], and 1–15
months for CP [7,41,42,44,48,58,60,63]. None of these studies
provided information regarding the amount of time per day
that the AFO was used. Radtka et al. instructed the partici-
pants to wear the AFO for the entire day over one month [7].
In order for AFO interventions to be successful, patients
must comply with wearing the device [70]. Studies that
evaluated patient satisfaction identified barriers to compli-
ance, such as weight, appearance, difficulty donning/doffing
and restriction of movement problems [11,19,28]. A study
by Beckerman et al. reported a 50% compliance rate due to
many problems related to both the AFO and placebo AFO
[11]. Specifically for the AFO group, the ROM caused an
unpleasant stretch on plantarflexor muscles and fitting the
AFO with footwear were the most frequent complaints [11].
Additionally, some patients were no longer able to don and
doff their AFO and footwear independently. These barri-
ers may limit an individual’s participation in daily activities
and in turn reduce the need for the device. It is likely that
improved participant satisfaction will increase compliance
and the amount of activities performed with the device.
Another issue that interacts with compliance is the
daily activity level of participants [71]. All the longitudinal
© 2012 Informa UK, Ltd.
AFO management in neuromuscular disorders  7
studies did not provided specific details on daily activi-
ties performed when using the device. It seems likely that
participants who regularly engage in physical activities,
such as walking, may perform better on follow-up mea-
sures. Previous research has indicated low levels of walking
activity among hospital inpatients and community-dwelling
stroke survivors [72]. Likewise, CP children were found to
have lower amounts of daily walking activity compared to
healthy controls [73]. A dose-response relationship has not
been established between duration and frequency of AFO
use, and functional outcomes in these populations. Likewise,
whether using an AFO facilitates higher levels of daily walk-
ing activity remains unknown. Walking activity may be a
significant confounding factor that has not been addressed in
the literature to date.
Outcome measures
Many studies highlighted the fact that footwear has an impact
on gait biomechanics and may potentially mask the AFOs
effect [13,44,46]. Studies with a barefoot control condition
often mention footwear as a limitation that may account for
changes in gait parameters [39,41]. ISPO guidelines recom-
mend that research report details of the footwear used in
adjunction with an AFO, such as heel-sole differential, design
of heel, stiffness and profile of sole, and any additional modi-
fications [67]. Churchill et al. examined the contribution of
footwear to the effect of AFOs on spatial-temporal gait param-
eters among five stroke survivors [13]. They found that stride
length increased significantly in a linear fashion for three
comparisons; barefoot–footwear–AFO with footwear [13].
In the CP literature, the majority of studies used a barefoot
baseline condition as a part of a standard clinical procedure to
analyze gait. Conversely, footwear was utilized in the control
condition more frequently in stroke research as compared to
CP (Tables IV and V). Hesse and coauthors compared three
conditions; barefoot, firm shoes, and AFO in chronic stroke
survivors with marked ankle plantarflexor spasticity [19]. The
footwear condition increased stride length and gait velocity
by 11 cm and 10 cm/s compared to barefoot gait, respectively
[19]. Wearing the AFO resulted in an additional significant
increase of 11 cm and 8 cm/s in these parameters [19]. The
effect of footwear on spatial-temporal gait parameters appears
to be evident and the degree of impact may depend on specific
features (i.e. weight and sole flexibility).
The effect of AFOs on outcome measures of gait and
functional mobility is provided in Tables VI and VII. Gait
was usually assessed via motion capture systems or pressure-
sensitive mats with participants walking at their self-selected
preferred or fast velocity. Spatial-temporal gait parameters
were most frequently reported for all populations. Gait veloc-
ity increased in 29/50 studies with an AFO compared to the
control condition [8,10,12,14,15,17–19,21–23,25,26,28,32–
34,36,37,39,40,44,46,47,59,60,62,65,66]. Interestingly, 7/14
stroke studies reported a significant increase for cadence
[10,19,21–23,28,33], while 9/20 CP studies observed a decline
in cadence with AFO use [8,41,42,46,56,59,60,65,66]. Studies
with CP children tend to report a greater extensive list of joint
 8  A. E. Chisholm & S. D. Perry

Table VI. Summary of AFO effects on gait outcome measures relative to the control condition for cerebral palsy studies.
Gait outcome measure
Author Year VEL STL CAD Increased No change Decreased
Middleton et al. 1988 Ankle DF in ST & SW
Hainsworth et al. 1997 Ankle ROM
Carlson et al. 1997 ---- ↑ ---- Knee ROM Ankle ROM
Radtka et al. 1997 ---- ↑ ↓ Ankle DF in IC & MST Knee kinematics, LE
muscle time
Abel et al. 1998 ↑ ↑ ---- Single ST time, knee FL Knee FL at IC Ankle ROM, ankle power
in SW, knee ROM in ST*
Brunner et al. 1998 ↑ ↑ ↓ Ankle DF in ST & SW Max knee FL in ST
Rethlefsen et al. 1999 ---- ---- ---- Ankle PF moment at TO Knee FL at IC Ankle PF at IC & TO
Crenshaw et al. 2000 ---- ---- ---- Ankle DF at IC & TO* Knee kinematics Ankle PF moment—TO*,
ankle power in ST
Suzuki et al. 2000 Energy cost
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Buckon et al.** 2001 ---- ↑ ↓ Ankle DF in ST & SW, Knee FL at IC & MST* Ankle power in ST
energy efficiency
Maltais et al. 2001 ---- Net heart rate, RER Net oxygen consumption
Dursen et al. 2002 ↑ ↑ ---- Stride width CGAS
Romkes et al. 2002 ---- ↑ ---- Ankle DF in ST & SW, ST phase %, knee EXT Ankle power at IC
knee FL in SW in ST
Thomas et al. 2002 ---- Ankle DF in ST & SW Single ST %
White et al. 2002 ↑ ↑ ---- Single ST %
Thompson et al. 2002 ↑ ↑ ↓ Ankle DF in ST Ankle ROM, knee FL
in ST
Kott et al. 2002 SWCO
Smiley et al. 2002 ---- ---- ---- Energy efficiency
For personal use only.

Buckon et al. 2004 ---- ↑ ↓ Ankle DF in ST & SW Hip & knee ROM Ankle ROM, energy cost,
ankle DF moment-ST
Hassani et al. 2004 Ankle DF in ST Knee EXT in ST & SW Ankle PF in SW
Park et al. 2004 Ankle DF, knee FL Hip ROM Sit-to-stand time
Radtka et al. 2005 ---- ↑ ---- Ankle DF in ST & SW, Knee kinematics, LE
ankle PF moment-TO muscle time
Lam et al.** 2005 ---- ↑ ---- Ankle DF in ST & SW, Ankle PF power in ST Ankle ROM
ankle PF moment-TO
Bjornson et al. 2006 GMFM scores
Romkes et al. 2006 ↑ ↑ ↑ Ankle DF at IC, hip FL ST phase %, knee FL TA muscle activity
at IC at IC
Desloovere et al. 2006 ↑* ↑* ↓ Knee FL in ST*, ankle PF Knee FL in SW Ankle PF in ST & SW,
moment-TO ankle ROM at TO
Balaban et al. 2007 ↑ ↑ Single ST time, ankle DF knee EXT in ST, knee FL Knee FL at IC
in ST in SW
Butler et al. 2007
Lucareli et al. 2007
Hayek et al. 2007 ↑ ---- ↑ ↓ --- Ankle DF in ST & SW Knee FL in ST & SW
Brehm et al. 2008 ↑ Energy cost
Van Gestel et al. 2008 ↑ ↑ ↓ Ankle DF ST & SW
Smith et al. 2009 ↑ ↑ ↓ Ankle DF in ST & SW, Ankle PF power at TO
ankle PF moment-TO
6MWT, 6-minute walk test; AFO, ankle-foot orthotic; CAD, cadence; CGAS, Clinical Gait Assessment Score; DF, dorsiflexion; EXT, extension; FL, flexion; GMFM, Gross Motor
Function Measure;IC, initial contact; LE, lower extremity; MG, medial gastrocnemius; MST, mid-stance; MSW, mid-swing; mEFAP, Emory functional ambulation;PF, plantarflex-
ion; RER, respiratory exchange ratio; ROM, range of motion permitted; ST, stance phase; STL, stride or step length; SW, swing phase; SWCO, standardized obstacle walking
course; TA, tibialis anterior; TO, toe-off; TUG, timed up & go profile; VEL, gait velocity; VL, vastus lateralis.
*Results varied for the parameter with different AFO types or control conditions

kinematics/kinetics parameters at the hip, knee and ankle,
while stroke research is usually limited to the ankle joint.
Electromyography (EMG) has been rarely used in AFO stud-
ies; the results show no change in lower extremity muscle acti-
vation timing. The energy cost of walking has been reduced
in 6/9 studies with use of an AFO compared to the control
condition [12,14,17,39,41,53].
Many standardized clinical tests have been developed
to evaluate gait and functional mobility, and they may bet-
ter reflect the activity domain. Among the stroke studies

Disability and Rehabilitation: Assistive Technology

 AFO management in neuromuscular disorders  9

Table VII. Summary of AFO effects on gait outcome measures relative to the control condition for stroke studies.
gait outcome measure
Author Year VEL STL CAD Increased No change Decreased
Mojica et al. 1988 ↑ ↑ ↑
Beckerman et al. 1996 ----
Hesse et al. 1996 ↑ ↑ ↑ ST & SW time symmetry
Hesse et al. 1999 ---- ---- ---- SW time symmetry, VL MG activity Ankle PF in SW, TA
activity activity
Tyson et al. 2001 ↑ ↑ ↑ Step length symmetry
Iwata et al. 2003 ↑ ↑ ↑
Gok et al. 2003 ↑ --- ↑ ankle DF in ST & SW Step time Knee FL moment*
Churchill et al. 2003 ---- ↑ ---- ST & SW times
Franceschini et al. 2003 ↑ Energy cost
Danielsson et al. 2004 ↑ O2 consumption Energy cost
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de Wit et al. 2004 ↑ TUG

Yokoyama et al. 2005 ↑ ↓ ST phase %
Sheffler et al. 2006 mEFAP
Wang et al. 2007 ↑ ↑ ---- ST & SW times Base width
Fatone et al. 2007 ---- ↑ Ankle DF at IC & MSW Step width
Rao et al. 2008 ↑ ↑ --- ↑
Bleyenheuft et al. 2008 ↑ ---- ---- Ankle DF at IC & MSW Ankle DF at MST, knee Mechanical work, energy
ROM cost
Abe et al. 2009 ↑ ↑ ↑ Step width Step length symmetry
Simons et al. 2009 ↑ 6MWT TUG
Fatone et al. 2009 ---- Ankle DF at IC & MSW, Knee FL moment at IC
ankle PF moment-TO
For personal use only.

Nolan et al. 2010 ↑ ↑ ↑ Ankle DF at IC Single ST time, ankle DF step width

at TO
Dogan 2010 TUG, Ashburn walk time
Chen et al. 2010 ---- ---- ---- Ankle DF in ST & SW*
Mulroy et al. 2010 ---- ---- ---- Ankle DF in ST & SW TA activity*
Jagadamma et al. 2010 ↑ ↑ Knee FL at IC, knee FL Knee EXT in ST, knee
moment EXT moment
Ohata et al. 2011 ↑ TA & MG activity at IC
Hung et al. 2011 6MWT mEFAP
6MWT, 6-minute walk test; AFO, ankle-foot orthotic; CAD, cadence; CGAS, Clinical Gait Assessment Score; DF, dorsiflexion; EXT, extension; FL, flexion; GMFM, Gross Motor
Function Measure;IC, initial contact; LE, lower extremity; MG, medial gastrocnemius; MST, mid-stance; MSW, mid-swing; mEFAP, Emory functional ambulation;PF, plantarflex-
ion; RER, respiratory exchange ratio; ROM, range of motion permitted; ST, stance phase; STL, stride or step length; SW, swing phase; SWCO, standardized obstacle walking
course; TA, tibialis anterior; TO, toe-off; TUG, timed up & go profile; VEL, gait velocity; VL, vastus lateralis.
*Results varied for the parameter with different AFO types or control conditions.

reviewed, the most commonly used scale was the Functional

Ambulation Category, which contains 5-points to assess
independence when walking. Orthotic devices may reduce
the amount of assistance or supervision required when
walking depending on environmental factors. In CP stud-
ies, the Gross Motor Function and Performance Measures
(GMFM and GMPM), and Pediatric Evaluation of Disability
Inventory (PEDI) were used most frequently to assess
changes in gross motor function (i.e., lying, sitting, stand-
ing, walking, running and jumping) [38,41,42,53,60]. The
GMFM and GMPM describe the ability to complete a task
and quality of movement (i.e., coordination and stability),
while the PEDI is a parental-reported general composite
of functional performance and caregiver assistance with
a mobility domain. AFOs may improve some gross motor
skills, such as standing and walking, depending on the
child’s type and severity of impairments.
Discussion
Rehabilitation for people with neuromuscular disorders is
often focused on improving or maintaining gait and func-
tional independence. This review examined the outcome of
AFO interventions with respect to clinical recommendations
for prescription and identified common limitations in current
research for knowledge translation. Individuals with stroke
and cerebral palsy demonstrated improved gait and functional
mobility with AFOs, such as increased gait velocity, greater
ankle dorsiflexion in stance and swing phases, and reduced
energy cost. However, most AFOs reduced lower limb ROM
and impaired power generation during the stance phase.
While the ISPO guidelines recommend different AFO types to
correct impairments in knee function during gait, the results
are inconsistent for changes in joint kinematics and kinetics.
The results of studies comparing the effects of different AFO

© 2012 Informa UK, Ltd.

 10  A. E. Chisholm & S. D. Perry
designs have suggested the benefits of each depending on the
individual’s type and severity of sensorimotor impairments.
Based on the current evidence, translating knowledge into clini-
cal practise is limited by a few factors, such as (i) understand-
ing the individual(s) diagnosis and impairments relative to gait
and functional mobility, (ii) identifying goals that the orthotic
will most effectively achieve, (iii) deciding on specific design
features, (iv) understanding contextual factors that may impact
functional outcomes, and (v) selecting outcome measures to
evaluate the orthotics effectiveness based on the stated goals.
Individual/study sample
Many articles raised concern regarding the heterogeneous
nature of neuromuscular populations and cited this as a
major factor contributing to inconsistent results across stud-
Disabil Rehabil Assist Technol Downloaded from informahealthcare.com by University of Calgary on 04/30/12
ies. Gait dysfunction associated with stroke and CP is caused
by both central impairments (i.e., motor and balance control,
sensory and coordination deficits) and subsequent localized
peripheral impairments (i.e., spasticity and muscle atrophy).
These impairments need to be evaluated to understand how
the health condition affects activity and participation, and
how an orthotic prescription may help improve gait and func-
tional mobility. Variability in reporting participant character-
istics may impede translation of results into clinical practice.
A complete evaluation may include muscle strength, ROM,
spasticity, motor control, sensation, fatigue, perceptual/cog-
nitive function and gait specific deviations. The expression
For personal use only.
of some impairments may change under different situations
(i.e. rest vs. walking), thus highlighting the importance of
gait-specific measures of impairment to characterize patients
[74,75]. A few studies used gait pattern classification systems
that describe kinematics deviations in the saggital plane
[59,60]. Although these systems assist with communication
between researchers and clinicians, each CP patient may not
fit completely into one category and they require an individu-
alized treatment plan [76]. In research, a detailed descrip-
tion of participants may facilitate a better understanding of
the influence on specific impairments and possibly advance
translation of research findings into clinical practice.
Goals of orthotics
The basic functional goals of orthotics are to provide sup-
port, manipulate deformities and/or modify motion occur-
ring at a joint by assisting or substituting [2]. Orthotics may
act directly (i.e., when it surrounds the segment or joint it is
attempting to influence) or indirectly (i.e., when it modifies
external forces acting on a joint it does not surround). It is
important to identify gait deviations and joint deformities that
may be most effectively managed by an AFO. Research studies
evaluating AFOs should state the intended actions relative to
the patient’s impairments and functional limitations during
standing and walking. These goals may be influenced by other
environmental (i.e., home and community) and personal fac-
tors (i.e., activity level, other health conditions).
Orthotics design
A common issue with reporting design characteristics of
AFOs is the lack of consistency of terminology used both
Disability and Rehabilitation: Assistive Technology
within and between professional groups [5]. There are several
challenges to orthotic research when studies fail to provide a
detailed description of the orthotic device. First, insufficient
details on the design may cause confusion in understanding
the biomechanical effects of the intervention. Second, system-
atic reviews and/or meta-analysis’ combine the effects of all
orthotic designs that leads to inconclusive outcomes suggest-
ing the potential for a beneficial effect. Finally, the ability to
reproduce results to confirm the effectiveness of an interven-
tion improves the quality and quantity of scientific evidence.
For a clinician translating research into practice, if a particular
device was found effective they may prescribe it for a patient
whom has similar clinical characteristics.
After review of ISPO consensus reports and relevant lit-
erature, it is recommended to include the following details
in research articles when appropriate; design category (i.e.,
articulating or nonarticulating), type and thickness of mate-
rial, calf piece height, initial alignment relative to ankle joint,
joint type, position of anterior trim lines relative to the ankle
malleoli, ROM permitted, use of springs and wire diameter/
spring constant, foot bed contouring, foot plate length, and
strapping system [77]. Prefabricated AFOs as opposed to
custom-made may be effective for some patients depending
on the severity of gait dysfunction and contextual factors.
Material properties, such as type and thickness, may have
a direct influence on the ROM permitted and subsequently
affect joint kinematics and kinetics in the gait cycle. The strap-
ping system, trim lines and foot plate length also determine
the ROM permitted, along with the type of force system used
to correct any joint misalignment. Reporting these details of
the orthotic design may facilitate a better understanding of
the effects on gait and functional mobility.
Contextual factors
Evaluating orthotics requires an understanding of contex-
tual factors, environmental and personal, that may influence
functional outcomes. These factors may directly influence
the decision making process regarding the intended goals
and AFO design. Many barriers to compliance have been
identified (i.e., appearance, weight, donning/doffing, etc)
and should be addressed prior to prescribing the orthotic
[11,28]. The type and amount of daily activities performed by
the patient will help determine the intended goals of using
the device. Footwear interacts with how the orthotic func-
tions during the gait cycle and may require adaptations to fit
the device. Previous research on healthy children has dem-
onstrated changes in spatial-temporal indices of gait with
footwear compared to barefoot [78,79]. Other health condi-
tions may determine specific features of the orthotic, such as
patients with edema may require an AFO with metal uprights
as opposed to a plastic material to adjust the fit. For rehabilita-
tion research, these factors need to be standardized or exam-
ined post intervention for potential confounding effects.
Outcome measures
Many studies used a standardized gait assessment with quan-
titative and objective outcome measures. These measures
included spatial-temporal parameters, muscle activation

patterns, oxygen consumption, joint kinematics and kinetics.
Standardized clinical tests may be included to measure per-
formance of other activities (i.e., gross motor skills), partici-
pation (i.e., daily activities at home or within the community
and quality of life) and contextual factors (i.e., patient satisfac-
tion). AFOs are commonly evaluated in a laboratory, which
typically does not capture the complexity of environmental
factors encountered at home and within the community (i.e.,
uneven terrain, stairs and ramps). It would be beneficial to
include variations of these factors in the evaluation of gait and
functional mobility.
Limitations
This review focused on describing evidence from research
Disabil Rehabil Assist Technol Downloaded from informahealthcare.com by University of Calgary on 04/30/12
AFO management in neuromuscular disorders  11
the Provincial Rehabilitation Research Program from the
Ministry of Health and Long-Term Care in Ontario. Support
was also provided by Natural Sciences and Engineering
Research Council (PGS-D), Canadian Institute of Health
Research (MOP-77772), and University of Toronto.
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The authors acknowledge the support of the Toronto
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