Grafo 736j57

GRF-AFO (FLOOR REACTION ORTHOSIS)

Suman Kumar Panda, 1ST YEAR, MPO, SVNIRTAR

This presentation is dedicated to Late Dr. A P J Abdul Kalam

FRAFO? or GRAFO? or AFRO? or FRO?

The ground reaction AFO (GRAFO) is a specific type of AFO that is designed to harness the ground reaction moment around the ankle to increase the stability of the knee in stance & also capable of triplanar control of the foot/ankle complex.

FRONTAL PLANE CONTROL- Inversion & Eversion SAGITAL PLANE CONTROL Dorsiflexion & Plantarflexion TRANSVERSE PLANE CONTROL -Rotations

HISTORY -Dr. Jimmy Saltiel from Israel (1969) -In India Dr. P.K.Sethia & Dr. S.C.Lakkad (1983) -DRDO in collaboration with Nijam Institute, Hyderabad made the glassfibrecomposite FRO under the leadership of Late Dr. APJ Abdul Kalam.

PREREQUISITES: -Appropriate alignment of the foot & knee (knee & hip flexion contracture not more than 10Degrees) -Presence of some trunk balance and/or the ability to use auxiliary walking aids in the event of diminished trunk balance.

RECIPE

BIOMECHANI CS

LAWS OF PHYSICS

ORTHOTI C DESIGN

BETTER OUTCOME

LAWS OF PHYSICS

-Newton’s 3rd Law -1st Class Lever (Use of the AFRO in Patients with Cerebral Palsy, 1983, Edwin D. Harrington et al)

1ST CLASS LEVER PRINCIPLE

NEWTON’S 3rd LAW To maintain the state of equilibrium (knee extension): for every knee buckling moment (action) the pretibial shell must provide an equal & opposite moment (reaction)

BIOMECHANICS

Plantar flexion–knee extension couple

-In normal gait during 2nd half of the stance phase, stability of the knee is maintained without quadriceps action by the mechanism called PF/KE couple. -GRF can be controlled by degree of ankle dorsiflexion (eccentric contraction of Soleus thus controlling forward motion of tibia over foot) during gait to increase or decrease the knee extension.

GRAFO DURING STANCE 3 ROCKERS (Fulcrum):

GRAFO DURING STANCE

ORTHOTIC DESIGN

ANTERIOR TIBIAL SHELL

RIGID ANKLE

PARTS The combination of these three components allow the plantarflexion-knee extension couple (PF/KE) to occur, causing a knee-extension moment.

FOOT PLATE

DETERMINANTS OF PF ANGLE & LENGTH OF PRETIBIAL SHELL Theoretically, when the orthosis is set in plantarflexion (510Deg), the extension moment is maximal but the forward progression is at least partially blocked. -Determining the angle depends on: sides of involvement & quadriceps strength

Design Variants

One piece: enclosing the back of the lower calf, the shin, and the bottom of the foot (Saltiel type ankle foot orthosis)

In June 1969, Jimmy Saltiel described an ankle foot orthosis which was designed to stabilize the paralyzed limb without limiting knee movement.

Two piece (clam shell): same as the one piece but with a removable anterior shell

- Generally the posterior section is pulled first.

Rear opening: encloses the front of the leg and top of the foot - Not a popular design - Sometimes recommended for post -op Achilles tendon repair

Composite AFO Design by Dynamic Bracing Solutions - Developed by Marmaduke Loke and Jean-Paul Nielsen. - The key to this design lies in the material composition and two flexible struts. - This flexibility provides two important elements: a dynamic response to propel the limb forward and a progressive resisting force near the knee.

Texas TURBO AFO by Advanced Orthopedic Designs - Developed by Kevin Matthews and his associates, the key to this design is the long polypropylene strut that runs from the medial arch proximally and across the tibia before running distally and terminating near the lateral malleoli.

Texas TURBO AFO by Advanced Orthopedic Designs - In contrast to the Composite AFO Design, this strut provides maximum rigidity and therefore can limit the majority of ankle/foot triplanar motions. - For this reason, Advanced Orthopedic Designs recommends the Texas TURBO AFO for PTTD, Achilles Tendonitis, Arthritis, Plantar Fasciosis, and any other diagnosis where ankle/foot motion is contraindicated.

SM FRO (Indian Made) - Standard Modular FRO - Consists of three modular pieces namely, foot piece, lateral uprights (glass reinforced PP) and knee piece.

INDICATIONS: Given in mainly neurological related issues i.e. -SPINA BIFIDA - -BRAIN INJURY -SCI -RFP

CONTRAINDICATIONS: -Hip, knee, and/or ankle flexion contractures -Moderate to severe pes valgus, tibial vara, genu varum/valgum, genu recurvation (ligament laxicity)

WEARING SCHEDULE & INSTRUCTION 1st Day: 1hr 2nd Day: 2hrs 3rd Day onwards increase an hour daily -If any redness or callus we should check the area of pressure -Different heel height shoes should be avoided -Heel should be properly seated

Why this design is not popular in India? -Inadequate good quality Liners -Skills for Vacuum plastic pulling -Good quality Reinforced plastics -Finishing tools -Prescribing KAFOs increases revenue -Lack of practise knowledge -No team work

References & Sources 1. Perry J. Normal and pathologic gait. In: Hsu JD, Michael JW, Fisk JR, eds. AAOS Atlas of Orthoses and Assistive Devices . 4th Ed. Philadelphia, PA: Mosby Elsevier; 2008:61. 2. An Advanced Ground Reaction Design Ankle-Foot Orthosis to Improve Gait and Balance in Individuals With Post-Stroke Hemiparesis: A Case Series: Jennifer Hale et al 3. Case Study: Improving Knee Extension with Floor-Reaction Ankle-Foot Orthoses in a Patient with Myelomeningocele and 20° Knee Flexion Contractures: Donald Freeman et al 4. Use of the AFRO in Patients with Cerebral Palsy, 1983, Edwin D. Harrington et al 5. Dynamic BracingSolutions™ 6. Advanced Orthopedic Designs, LLC 7. http://www.oandp.org/jpo/library/2013_01_042.asp 8. http://orthopedia.wikia.com/wiki/Ground_Reaction_AFO 9. http://www.oandplibrary.org/op/pdf/1983_04_034.pdf

“A PIECE OF PLASTIC IF PROPERLY FITTED, CAN DO WONDERS” -Dr. A P J Abdul Kalam