November 2011

Bespoke for stroke: Temporary custom shoe improves gait

In the moment: Footwear

The temporary shoe used in the study takes two weeks to manufacture. Image courtesy of Gerard Ribbers, MD, PhD.

By Emily Delzell

Recent research from the Netherlands suggests that a custom-made orthopedic shoe designed for temporary use can enhance early mobilization after stroke, improving functional mobility, walking speed, and gait.

In the aftermath of stroke, it’s not always clear how much walking ability patients will regain or what kind of permanent orthoses they will need, if any. Consequently, Dutch researchers compared the effects on gait characteristics of a normal shoe versus a temporary custom shoe meant to be discarded after rehabilitation and, if needed, replaced with a permanent custom orthotic device.

Investigators, who published their findings in October in Gait & Posture, recruited 19 stroke patients (12 men, seven women; mean age, 55 years, range, 32-55 years) with a mean poststroke time of 3.6 months (range, two to eight months). All had varying degrees of hemiplegia with spastic paresis and could walk without assistive devices for at least 20 m in normal shoes.

The custom shoe used in the study (pictured above) was a high orthopedic shoe with a stiff leg made of carbon fiber and paired with a normal shoe corrected for sole thickness.

“This shoe can be manufactured in two weeks, offers stability at the ankle and knee, and prevents dropping of the foot in swing phase,” said study author Gerard M. Ribbers, MD, PhD, an associate professor at Rijndam Rehabilitation Centre and in the Department of Rehabilitative Medicine at Erasmus Medical Center in Rotterdam.

In addition to comparing functional mobility, walking speed, and gait between the two shoe conditions, researchers also evaluated patient satisfaction with walking using several measures, including ease of lifting the foot, confidence, estimated speed, and others, as well as the effect of dual task interference.

“Physical therapy sessions often take place in a sheltered environment and in the absence of distractors such as traffic and talking,” Ribbers said. “Patients may be able to perform a task such as walking in a rehabilitation center, for example, but when they have to shift their attention to outside environmental stimuli, task performance can decrease.  We controlled for dual task interference to test patients’ abilities in real-world conditions.”

Ribbers and colleagues tested patients’ dual task performance by having them reply verbally to auditory questions while undergoing walking trials in the custom and normal shoes. The team tested function with a timed up and go test (TUG) and gait characteristics on a 9-m walkway, recording step length and width, stance duration, cadence and walking speed, and clearance and knee flexion angle of the affected leg.

Compared with the normal shoe condition, the custom condition reduced TUG times by 22% and increased walking speed by 37%, cadence by 17%, and step length of the affected leg and nonaffected leg by 12% and 34%, respectively. The custom shoe also decreased stance duration in the affected and nonaffected leg by 18% and 16%, respectively, and step width by 12%. Investigators found no significant differences in clearance or knee extension.

Dual task performance interfered with functional mobility in both shoe conditions, but had no effect on walking speed and other gait characteristics. Investigators found no significant differences between conditions for any dual task measures.

Overall, the patient satisfaction questionnaire showed participants favored the orthopedic shoe (p<0.001), said Ribbers, and the majority reported improved satisfaction from baseline in all measures. A third of individuals, however, said the custom shoe’s weight interfered with lifting the foot.

“Such a shoe may make the difference between walking and not walking,” Ribbers said. “In general, it’s most appropriate for individuals with high tonus, severe equinovarus, or knee hyperextension, as well as for some individuals with vascular problems in whom a regular orthosis might increase the risk of pressure ulcers. It can be manufactured quickly, worn in home settings, and discarded when patients are ready for a permanent orthosis.”

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