AFO: You can check out anytime you like, but can you ever leave?

I often get questions about ankle foot orthoses (AFOs), and how to get out of them. I'm not a big fan of AFOs because they encourage a sort of "learned nonuse." It's actually more like "learned disuse." (Learned disuse: You're not learning to not use the body part, but you learning to use body part incorrectly.) And keep in mind, every movement you make changes the way your brain is wired. So it's very easy to get used to an AFO. Let's put it this way:

It's easy to walk into an AFO. It's hard to walk out.

In any case, I get a lot of e-mails about this subject. Here's an example:
 
I wear a big brace on my right leg. I am paralyzed on the right side. I walk with a one-point cane. I walk with an open hinge (articulating) AFO.
 
They opened the hinges on my old brace several years ago. I walk around my apartment with the old one. But when I go out I use the bigger brace which isn't open at hinges.
 
I read on Deans' Stroke Musings that you recommend the Air Cast. Which one for stroke survivor do you like? They have a lot of different ones on their website.

Here's my answer:

First of all, the disclaimer:

(Warning: ENDING THE USE OF AN AFO CAN LEAD TO FALLS AND INJURIES.

Never discontinue the use of an orthotic without first consulting the appropriate health care provider. Then call your doctor. Then have your doc talk to any other providers as needed. Then discuss it some more. Thank you.)

Wear a brace on the ankle that satisfies two things:
1. Keeps you safe
2. Challenges* you

*Challenge: Walking naturally challenges you to lift your foot. If you can lift your foot up and down to stay safe (not trip) then you might consider questioning an orthotic that helps lift the foot.

Gradation would usually be something like this:
1. Rigid AFO
2. Articulating AFO (where the ankle joint moves just a little bit)
3. A stirrup (stabilizes both sides the ankle but allows the ankle to move up and down freely)
4. A high top shoe (like a basketball shoe)
5. Nothing

Often the manufacturers are the best people to ask specific questions. One of the advertisers on this blog X-STRAP (see link on the sidebar) has a variety of products. Some help bring the ankle up during gait, others support the ankle. The stirrup is usually associated with one particular company: AirCast.

~

Use what you've got to get what you need.

If you've had a stroke, your spinal cord still works fine. The spinal cord takes over some aspects of movement. The first step in this process of the spinal cord taking over is spasticity. The brain can't move you, so spasticity, generated in the spinal cord, takes over. And as much as we hate spasticity, things could be worse. Spasticity is better than nothing. "Nothing" in this case would be a completely flaccid affected ("bad") side. And being flaccid is worse than being spastic. Trust me on this.

But if we go a step beyond spasticity towards recovery there is an intermediate step. This intermediate step is known as synergy. The spinal cord basically allows for basic movements. The brain is not working, the spinal cord takes over, and the spinal cord allows very basic movements.

The synergies, although often disparaged by clinicians, are brilliant. In the upper extremity, synergy allows for the most important movement you can imagine: 

 

Feeding. It looks like this...

 

In the lower extremity the flexor synergy looks very much like a stepping pattern.

Clinicians have, for 40 or 50 years or so, said that synergies are bad. I disagree. Synergies can be used in a way that replicates good coordinated movement. Synergies give you the ability to at least attempt to replicate a normal movement. Enough attempts and the brain rewires and the synergies are discarded.

Watch this video. This stroke survivor (Brian Redd) is on the right track... use what you have to get more. 

(At 2:35 he provides a stellar description of the flexor and extensor synergies of the leg).

Brain + Comfort Zone = No Gain

The key to recovery is challenge. Heck, the key to learning anything new is challenge. (For stroke survivors movements that need to be re-learned are "new.")

So how much challenge is needed? Let's put it this way, one of the treatments used to improve quality and speed of walking that seems very promising is called "speed dependent treadmill training." How challenging is it? Check this out…

The survivor gets on a treadmill and harnessed to the ceiling with a strap around their chest, just under their arms. The strap doesn't do anything – it's just a safety belt so if they fall, they don't fall- if you fall oh. (heh heh- still got it!)

The speed of the treadmill is turned up until either the therapist or the stroke survivor freaks out. Trust me, I'm only nominally paraphrasing here.

The "freak out" speed is considered the survivor's top speed. The survivors then rests for about five minutes. Then he gets back on the treadmill, harnessed again, and the speed of the treadmill is brought to half of his top speed for two or three minutes – as a warm-up.

The speed of the treadmill is then increased to their top

speed. If they can handle their top speed for 10 seconds, the speed of the treadmill is increased 10%. If they can handle that, there speed is increased another 10%. If they stumble it comes down 10%. But if they can then handle that for 10 seconds it increases 10%.

For this treatment, if speeds are plotted on a graph it looks kind of like the stock market – you have peaks and valleys but your speed is quicker at the end then at the beginning.

Think about that. The level of challenge is increased so much that it's defined by the person stumbling. This is where the brain operates. A safe brain does not grow. The brain has to be brought way outside it's comfort zone or doesn't change. True for anyone trying to learn anything. True for stroke survivors.