Prevent knee buckling without actually including knee in orthosis Sense of freedom and more control over external devices Light weight- 300gms Cosmetically acceptable Prevents pressure sore Easy maintenance

1. FLOOR REACTION ANKLE
FOOT ORTHOSIS
DR JOE ANTONY
MD
PHYSICAL MEDICINE AND REHABILITATION
KGMU

2. Floor reaction AFO
Aka, Ground reaction AFO (GRAFO)
Moulded to fit around the front of leg
A stance control orthosis
AAOS ATLAS OF ORTHOSIS AND ASSISTIVE DEVICES 2
Dr Joe Antony

3. Parts
AAOS ATLAS OF ORTHOSIS AND ASSISTIVE DEVICES
THE HELP GUIDE TO CP 3
Anterior tibial shell- just below tibial
tuberosity
Uprights
Foot Plate and fixed
ankle joint
Dr Joe Antony

4. Materials
Plastic AFO
Anterior strap in children below 15 kg
Rigid GRAFO in children above 15 kg
Functional benefit will depend on
work quality of orthotist
AAOS ATLAS OF ORTHOSIS AND ASSISTIVE DEVICES
THE HELP GUIDE TO CP 4
Dr Joe Antony

5. Indications
Quadriceps weakness
Most typical in post polio residual paralysis-
Hand Knee gait.
Crouch Gait in Cerebral palsy
AAOS ATLAS OF ORTHOSIS AND ASSISTIVE DEVICES 5
Dr Joe Antony

6. Relevant discussion on normal gait
INITIAL CONTACT LOADING RESPONSE
AAOS ATLAS OF ORTHOSIS AND ASSISTIVE DEVICES
6
MID STANCE PROGRESSION
Dr Joe Antony

7. Role of
Quadriceps
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Dr Joe Antony

8. Compensation for weak quadriceps
Hyper extend and lock the knee
Lean the trunk forward
Stabilize the knee with hand
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Dr Joe Antony

9. Bio-mechanics of GRAFO
AAOS ATLAS OF ORTHOSIS AND ASSISTIVE DEVICES
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10. Pre requisites
Absence of flexion contracture of hip and knee exceeding 10 degrees
Static as well as dynamic knee flexion deformity must be corrected before prescribing GRAFO
Trunk balance
A minimum grade 3 power of Quadriceps
THE HELP GUIDE TO CP 10
Dr Joe Antony

11. Advantages
Prevent knee buckling without actually including knee in orthosis
Sense of freedom and more control over external devices
Light weight- 300gms
Cosmetically acceptable
Prevents pressure sore
Easy maintenance
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Dr Joe Antony

12. Disadvantages
Relatively expensive
Must be custom made and correct fitting- otherwise poor functional outcome
Abnormal appearance on sitting
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Dr Joe Antony

13. Evidence for
GRAFO
BÖHM H, MATTHIAS H, BRAATZ F, DÖDERLEIN L. EFFECT OF FLOOR REACTION ANKLE-FOOT
ORTHOSIS ON CROUCH GAIT IN PATIENTS WITH CEREBRAL PALSY: WHAT CAN BE EXPECTED?
PROSTHET ORTHOT INT. 2018 JUN;42(3):245-253. DOI: 10.1177/0309364617716240. EPUB 2017
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14. Thank you
REFERENCES
1. The HELP guide to cerebral palsy
2. AAOS Atlas of orthosis and Assistive devices
3. Braddoms textbook of PMR
4. Böhm H, Matthias H, Braatz F, Döderlein L. Effect of floor reaction ankle-foot orthosis on crouch
gait in patients with cerebral palsy: What can be expected? Prosthet Orthot Int. 2018 Jun;42(3):245-253.
doi: 10.1177/0309364617716240. Epub 2017 Jul 11. PMID: 28693377.
5. Arazpour M, Gholami M, Bahramizadeh M, Sharifi G, Bani MA. Influence of Reciprocating Link
When Using an Isocentric Reciprocating Gait Orthosis (IRGO) on Walking in Patients with Spinal Cord
Injury: A Pilot Study. Top Spinal Cord Inj Rehabil. 2017 Summer;23(3):256-262. doi: 10.1310/sci16-00016.
Epub 2017 May 4. PMID: 29339901; PMCID: PMC5562033.
6. Campbells textbook of operative orthopedics
7. Mueller M.J, Diamond J.E, Sinacore D.R, et al. Total contact casting in treatment of diabetic
plantar ulcers. Controlled clinical trial. Diabetes Care . 1989;12(6):384–388. PMID: 2659299
8. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB: Off-loading the
diabetic foot wound: a randomized clinical trial. Diabetes Care. 2001;24(6):1019–1022.
9. Messenger G, Masoetsa R, Hussain I. A Narrative Review of the Benefits and Risks of Total
Contact Casts in the Management of Diabetic Foot Ulcers. J Am Coll Clin Wound Spec. 2018 Jun 7;9(1-
3):19-23. doi: 10.1016/j.jccw.2018.05.002. PMID: 30591897; PMCID: PMC6304285.
10. Cakar E, Durmus O, Tekin L, Dincer U, Kiralp MZ. The ankle-foot orthosis improves balance and
reduces fall risk of chronic spastic hemiparetic patients. Eur J Phys Rehabil Med. 2010 Sep;46(3):363-8.
Epub 2010 Jul 1. PMID: 20927002.
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