The Neurophysiological

Ankle-Foot Orthosis
by Cyndi Ford, P.T.
Robert C. Grotz, M.D.
Joanne Klope Shamp, C.P.O.

1
Since the late 1960's when Y a t e s and Although tone-reducing AFO's inhibit ab­
2
Lehneis wrote the first articles pertaining to normal hypertonicity in the affected lower ex­
the use of plastics, orthotic practice has been tremity, the disadvantages inherent in tradi­
revolutionized by the design possibilities af­ tional A F O ' s persist. Limited ankle dorsi-
forded by total contact devices. However, pre­ flexion and plantar flexion, create a negative
scription of lower extremity orthoses for neuro- influence upon independent knee and hip func­
logically involved patients has traditionally de­ tion. Floor reaction forces intended to prevent
pended solely upon biomechanical principles the typical hemiplegic knee recurvatum during
even as neurophysiological approaches to treat­ stance phase also contribute to increased effort
ment gained recognition and acceptance. Neur- and decreased smoothness in gait. Tonic foot
odevelopmental Techniques (NDT) were devel­ reflexes elicited by contact on the plantar sur­
oped as a theory of Karl and Berta Bobath and face of the foot as a means to facilitate normal
evolved to " a sensorimotor approach to control movement are disregarded.
motor output and in doing so change sensory In an effort to address these gait concerns, an
3
input." Handling techniques which counteract orthosis was designed based upon the neurode-
patterns of abnormal tonic reflex activity re­ velopmental concepts as described by Bobath 5

duce spasticity and allow facilitation (activa­ 6

and Utley , and the foot reflexes as described
tion) of normal postural reactions through stim­ 7
by Duncan and Mott with the following con­
ulation of key points of control, which include siderations in mind:
points on the foot and ankle. Recent advances
incorporating neurophysiological principles of
inhibition and facilitation into the design of 1. A design configuration intended to utilize
ankle-foot orthoses make possible tone-re­ both biomechanical principles to limit
ducing devices with specific areas of pressure calcaneal varus and neurophysiological
or contact to inhibit abnormal hypertonicity. principles (of facilitation and inhibition)
4
Eberle, Jeffries, and Zachazewski recently to obtain dynamic ankle dorsiflexion and
reported success with an inhibitive AFO, a plantar flexion.
concept that was not feasible with metal or­ 2. Selection of a material with adequate
thotics. Their report stated that "the technique flexibility, durability, and shape retention
of fabrication used for the construction of a under conditions of continual deforma­
molded polypropylene AFO allows for all of tion during ambulation.
the tone-inhibiting characteristics of casting 3. Ease of donning for the one-handed pa­
. . . to be built into the A F O . " tient.
DESIGN RATIONALE 5. A neurophysiological force to inhibit the
toe grasp reflex (toe flexors and gastroc-
The Neurophysiological Ankle-Foot Orthosis nemius-soleus) by unweighting of the
(NP-AFO) is a custom polypropylene device, metatarsal heads through use of a meta­
vacuum-formed over a plaster model of the pa­ tarsal arch (Figure 6).
tient's affected lower extremity (Figure 1). 6. Biomechanical function through flexi­
Within the total contact design are incorporated bility of the foot and ankle due to the
the following forces: trimlines and configuration of the plastic
NP-AFO (Figures 7 and 8).
1. A three-point pressure system to biome-
chanically control calcaneal varus (Fig­
ure 2). PRESCRIPTION
2. A biomechanical force medial to the
achilles tendon to counterbalance and
RATIONALE
prevent excessive pronation and rotation The NP-AFO is designed for use in the treat­
of the orthosis in the shoe (Figure 3). ment of the patient with a central nervous
3. A neurophysiological force on the medial system disorder, such as a cerebral vascular ac­
aspect of the calcaneus, extending to the cident or closed head injury. Assessment
plantar surface of the longitudinal arch should include analysis of the individual's tone
without creating pressure under the navi­ or spasticity, range of motion, and the avail­
cular itself (Figure 3). This facilitates ability of follow-up by members of the clinic
straight plane dorsiflexion. team familiar with a neurophysiological ap­
4. A neurophysiological force on the lateral proach to care. Spasticity has been classified as
aspect of the plantar surface of the foot minimal, moderate, or severe in terms of func­
9
(Figures 4 and 5) to facilitate the eversion tion of the foot and ankle during gait. Minimal
reflex (peroneals) and recruit more prox­ spasticity allows the patient to land on a stable
imal controls (vastus lateralis and gluteus calcaneus without excessive supination of the
medius) for knee and hip stability as dis­ forefoot and then shift the body weight over the
8
cussed by Duncan . The amount of dorsi­ heads of the metatarsals, although during swing
flexion assist may be graded by adjusting phase the foot assumes a varus or supinated
the width of the segment joining the heel- posture. Moderate spasticity causes the cal­
cup and the metatarsal arch (Figure 5). caneus to assume a position of varus with ex-

Figure 3.
Figure 1. Figure 2.
Figure 4. Figure 5. Figure 6.

Figure 7. Medial view, left foot. Figure 8. Lateral view, left foot.
 cessive supination at initial contact; however,
during midstance some pronation occurs and
the body weight can again be transferred nor­
mally across the forefoot. Severe spasticity is
characterized by the foot and ankle being held
rigidly in a position of equinovarus throughout
stance so that the body weight remains on the
lateral aspect of the forefoot with little or no
weightbearing through the heel or medial meta­
tarsal heads. This varus position persists
throughout swing phase also.
Figure 9. Toe s e p a r a t o r s fabricated from Plastazote® Patients exhibiting minimal or moderate
with a Moleskin® cover a n d toe extension.
spasticity are excellent candidates for the NP-
AFO. Patients with severe spasticity are candi­
dates only if their tone can be modified through
handling techniques and/or inhibitive casting.
The use of toe separators (Figures 9,10,11) as
an adjunct treatment is also effective in patients
with a separate toe grasp reflex to inhibit excess
6
tone and reduce pain. In order for the NP-AFO
to function appropriately, the patient must have
at least 15 degrees of passive dorsiflexion with
the knee in flexion.
Follow-up by a clinic team familiar with the
device is important to monitor the continued fit
and function. With most AFO's the major con­
Figure 10. Toe s e p a r a t o r s in place u n d e r the toes.
cern may be skin breakdown. However, with
the NP-AFO the change in fit due to edema,
weight loss, or tone variations may require
modifications to maintain the critical areas of
contact.
Contraindications for this device are severe
spasticity which cannot be modified through in­
hibitive casting or handling techniques, and
early excessive pronation or calcaneal valgus
with the foot pronated at initial contact of
stance.

CLINICAL EXPERIENCE
The NP-AFO has been prescribed for 35 pa­
tients with the following diagnoses: 29 Cerebral
Vascular Accidents (CVA), 4 Closed Head In­
juries (CHI), 1 Cauda Equina Injury, and 1 un­
diagnosed Demyelinating Disease. Although
three patients were lost to follow-up, the NP-
AFO has continued to be worn by the re­
maining 32 with overwhelming acceptance
which seems to be attributed to the comfort and
function of the device. Of the four patients
Figure 1 1 . S u p e r i o r view showing tabs to hold in place converted from traditionally designed orthoses
u n d e r sock. (2 metal, 2 plastic A F O ' s ) , three have im-
 proved gait patterns and prefer the NP-AFO to use in vacuum-forming of the orthosis. The
their previous device. The fourth has rejected positive model is now ready for modifications
orthotic care due to refusal to adapt footwear to create the necessary biomechanical and neu­
from inappropriate styles with 21/2"heels. Four rophysiological forces.
patients b e c a m e i n d e p e n d e n t a m b u l a t o r s
without the use of any orthotic device.

FABRICATION MODIFICATION OF THE

Polypropylene was chosen as the thermo­
POSITIVE MODEL
plastic currently exhibiting the best confor­ As the key to function of the orthosis is se­
mance to the desired qualities, when used in the lective inhibitive and facultative forces, accu­
fabrication process described. rate cast modification is essential. Plaster re­
moval is performed in the following areas to a
depth of 0.5 to 1 cm. depending upon the com­
CASTING PROCEDURE pressibility of the patient's extremity. These
The casting technique is similar to that de­ modifications must be sufficient to provide a
scribed in Lower Limb Orthotics, A Manual 10
very firm force to the skin as designated.
and is a procedure commonly used by certified
orthotists. The cast must be taken in a position 1. Medial and lateral to the achilles tendon
of maximal dorsiflexion, preferably 20 de­ using a Scarpa's knife to deeply groove
grees. The calcaneus, midfoot, and forefoot the modification (Figure 12).
should be in a neutral position. It has been our 2. Medial aspect of the calcaneus extending
experience that tone-reducing handling activi- to the plantar surface of the longitudinal
. ties performed by a physical therapist just prior arch without creating pressure under the
to casting will help assure an optimal position. navicular itself that would stimulate mid
These activities include forefoot, midfoot, and and forefoot supination (Figure 13).
6
hindfoot mobilizations as taught by Jan Utley. 3. Along the lateral plantar surface of the
The cast is removed upon hardening and mid- and forefoot, excluding the base and
filled with plaster to create a positive model for head of the fifth metatarsal (Figure 14).

Figure 13.

Figure 12.

Figure 14.
 Figure 16.
Figure 15. Figure 17.

4. Create a metatarsal arch 6mm. proximal TRIMLINES

of the metatarsal heads for the inhibitive
function of unweighting the metatarsal The orthosis is removed from the positive
heads and thereby reduce tone (Fig­ model using a cast cutter and is sanded to finish
ure 6). according to the following trimlines:
5. Smooth entire cast. 1. Overall height of the orthosis is equal to
If an accurate negative cast and posi­ the distance from the plantar surface of
tive model were created, no further modi­ the calcaneus to the flare of the achilles
fications are necessary. tendon as it meets the gastrocnemius-
s o l e u s g r o u p , m u l t i p l i e d by 2. An
average overall length for a 175cm. (5'9")
adult is 25.5cm. (10").
VACUUM-FORMING 2. Length of the plantar extension is termi­
nated 6mm. proximal to the metatarsal
PROCESS heads for comfort.
Leather, nylon, or rope cording is applied 3. The lateral trimlines (Figure 18) come as
to the cast (Figures 1 5 , 1 6 , 1 7 ) to create far anterior as possible and still allow
strengthening corrugations in the orthosis after passage of the leg into the orthosis. The
molding. posterior trimline (Figures 18 and 19) ap­
A separating agent or material is used be­ proaches the lateral margin of the achilles
tween the positive model and the hot plastic to tendon, but may require modification to
create adequate vacuum and to leave a smooth prevent a bowstring effect by the heel
inner surface. For our drape-forming process counter of the shoe against the NP-AFO.
one layer of perlon with one layer of ladies' Note that flexibility is enhanced by the
nylon knee-high stockings are applied and narrowing anteriorly and posteriorly as
smoothed with talc. Stress-relieved 3/16" poly­ the lateral side meets the heelcup.
propylene is then drape-formed under vacuum 4. The achilles tendon is left exposed to the
to the positive model and allowed to cool for 24 point of flare with the gastronemius-
hours. soleus (Figure 19).
Figure 18.
Figure 19.

Figure 2 0 . Figure 2 1 .
 5. The medial margin is trimmed so as to other AFO's. Without these abnormal forces,
provide the appropriate forces and yet the patient experiences the normal movement
avoid contact on the medial malleolus and of the pelvis and knee over the foot, allowing
under the navicular. The open area pro­ development of a propulsive toe-off with the
vides for lack of resistance to dorsiflexion NP-AFO.
and plantar flexion (Figures 20 and 21). Progressing from use of the NP-AFO to
6. The plantar extension (Figure 21) may be being independent of assistive devices is more
varied in width depending upon the size feasible, as the patient has the opportunity to
of the patient and flexibility desired, but gain control of muscles through the normal
as it serves only to join the metatarsal range of movement.
arch to the heelcup, it should remain as
flexible as possible. The distal aspect, in­
cluding the metatarsal pad, should span SUMMARY
the distance between the shaft of the first The adequacy of traditional AFO's to pro­
metatarsal and the extreme lateral margin vide a safe, functional gait pattern is irrefut­
of the foot to allow maximum facilitation able. However, experience with patients who
of the eversion reflex. sustained a CVA five to fifteen years ago and
A full 1/8" Plastazote® liner is glued to the received a traditional metal or plastic AFO re­
inner surface of the orthosis, with the exception veals they now present problems related to
of the areas contained by the patient's shoe to overuse of the sound side: the pathomechanics
allow ease of donning the same size shoe pre­ resulting from a rigid ankle and/or increasing
viously worn by the patient. A Velcro® strap of hypertonicity from abnormal weightbearing
2" width is applied to the proximal anterior patterns. As more patients have increased life­
calf. A lace-tied or Velcro®-closed shoe is rec­ spans following a CVA, treatments and orthotic
ommended to maintain the critical fit of the care which assure prolonged quality of life be­
NP-AFO. come increasingly important. Neurophysiolog­
ical treatment attempts to do this through em­
phasis upon normal movement patterns and in­
DISCUSSION tegration of the affected and unaffected sides.
The NP-AFO is a biomechanically and neu-
The movement allowed by the NP-AFO en­
rophysiologically effective ankle-foot orthosis
courages dynamic control of the entire lower
that is appropriate for creating a functional gait
e x t r e m i t y . W h e n sitting, normal weight-
bearing attitude can occur with the foot re­ in the patient with a central nervous system dis­
m a i n i n g in full c o n t a c t with t h e floor order. The design allows for independent mo­
throughout a full range of knee flexion. Anal­ tion at the ankle, knee, and hip joints in a light­
ysis of the normal movements of the ankle weight and cosmetic custom-made orthosis.
during elevation from a chair has revealed to us The NP-AFO joins the inhibitive cast and other
that the ankle begins in dorsiflexion and con­ neurophysiological armamentarium in new ap­
tinues to dorsiflex during the initial phase of the proaches to the rehabilitation of the spastic or
elevation before plantar flexing to a relatively hypertonic patient.
neutral position. Devices which eliminate this
normal range of dorsiflexion necessarily re­
quire a patient to work over an abnormal base REFERENCES
and make difficult active weight-bearing during 1
Yates, G., "A Method for Provision of Lightweight
elevation. The ability to assume a normal Aesthetic Orthopaedic Appliances," Orthopaedics: Ox­
ford, 1:2, pp 1 5 3 - 1 6 2 , 1968
weight-bearing surface in a position of power 2
Lehneis, H.R., "New Concepts in Lower Extremity
as allowed by the NP-AFO encourages weight- Orthotics," Medical Clinics of North America, [Link], pp.
bearing on the affected extremity throughout all 5 8 5 - 5 9 2 , 1969.
activities of daily living. 3
Bobath, K., "The Problem of Spasticity in the Treat­
ment of Patients With Lesions of the Upper Motor
Further, dynamic control of the pelvis and Neurone," The Western Cerebral Palsy Centre, London,
knees are encouraged during ambulation by England.
eliminating floor reaction forces inherent in 4
Eberle, E . D . ; Jeffries, M.; and Zachazewski, J.E.,
"Effect of Tone-Inhibiting Casts and Orthoses on Gait: A Freedman and Herman, "Inhibition of EMG Activity in
Case Report," Physical Therapy, 62:4 pp. 4 5 3 - 4 5 5 , 1982. Human Triceps Surae Muscles During Sinusoidal Rotation
5
Bobath, B. and Bobath, K., Motor Development in of the Foot," Journal of Neurology, Neurosurgery and
Different Types of Cerebral Palsy, Heinman, London, Psychiatry, 1975:38, pp. 3 3 6 - 4 5 .
1975. Knutsson, E. et al., "Different Types of Disturbed
6
Utley, J., NDT Adult Hemiplegia and Closed Head In­ Motor Control in the Gait of Hemiparetic Patients," Brain,
jury Certification Course, Columbus, Ohio, July, 1982. 1979:102, p. 405.
7
Duncan, W. and Mott, D . , "Foot Reflexes and the Use Lehmann, J.F., "Biomechanics of Ankle-Foot Orthoses:
of the Inhibitive Cast," Foot and Ankle, p. 145, 1983. Prescription and Design," Archives of Physical Medicine
8
Duncan, W., "Tonic Reflexes of the Foot," Journal of and Rehabilitation, Volume 60, May, 1979, p. 200.
Bone and Joint Surgery, July, 1960. Ibid, "Plastic Ankle-Foot Orthoses: Evaluation of Func­
9
Sarno, J.E. and L e h n e i s , H . R . , " B e l o w - K n e e tion", Archives of Physical Medicine and Rehabilitation,
Orthoses: A System for Prescription," Archives of Physical p. 402.
Medicine and Rehabilitation, Vol. 54, p. 548, December, Ibid, "A Biomechanical Evaluation of Knee Stability in
1975. Below-Knee Braces," Archives of Physical Medicine and
1 0
Rehabilitation Engineering Center, Moss Rehabilita­ Rehabilitation, p. 688, December, 1970.
tion Hospital. Lower Limb Orthotics: A Manual, First Edi­ Manfredi, Sacco and Sideri, "The Tonic Ambulatory
tion, Philadelphia, 1978. Foot Response," Brain, 1975: 98, pp. 1 6 7 - 8 0 .
Perry, et al., "Determinates of Muscle Action in Hemi­
paretic Lower Extremity," Clinical Orthopaedics and Re­
lated Research: p. 131, March-April, 1978.
ADDITIONAL READING Walters, R.L., "The Enigma of 'Carry Over'," Interna­
Bobath, B. "The Application of Physiological Principles tional Rehabilitation Medicine, 1984:6, pp. 9 - 1 2 .
to Stroke Rehabilitation—A Special Report," The Practi­ Watemabe, I. and Obubo, J., "The Role of Plantar Me-
tioner, December, 1979, Vol. 223, 7 9 3 - 4 . chanoreceptor in Equilibrium Control," Ann-NY-ACAD-
Ibid, "The Treatment of Neuromuscular Disorders by Science, 1981: 374, pp. 8 5 5 - 6 4 .
Improving Patterns of Coordination," Psychotherapy. Weiz, S., "Studies in Equilibrium Reaction," Journal
Bobath, B. and Bobath, K., "The Importance of of Nervous and Mental Disorders: 88, 1938, p. 150.
Memory Traces of Motor Efferent Discharges for Learning
Skilled Movement," Developmental Medicine and Child
Neurology, 1974, p. 16, pp. 8 3 7 - 8 .
Cherry, D . B . , "Review of Physical Therapy Alterna­
AUTHORS
tives for Reducing Muscle Contracture," Physical Cyndi Ford, P.T., is with the Edwin Shaw Hospital in
Therapy, Volume 60, Number 7, p. 877, July, 1980. Akron, Ohio.
Effgen, S., "Integration of the Plantar Grasp Reflex as Robert C. Grotz, M . D . , is Medical Director for Edwin
an Indicator of Ambulation Potential in Developmentally Shaw Hospital in Akron, Ohio.
Disabled Infants," Physical Therapy, Volume 62, Number Joanne Klope Shamp, C.P.O., is with the Shamp Pros-
4, pp. 4 3 3 - 3 5 , April, 1982. thetic-Orthotic Center in Norton, Ohio.