AS MANY AS 88% of individuals who have suffered an

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1 478 The Effect of Shoe Wedges and Lifts on Symmetry of Stance and Weight Bearing in Hemiparetic Individuals Gianna M. Rodriguez, MD, Alexander S. Aruin, PhD ABSTRACT. Rodriguez GM, Aruin AS. The effect of shoe wedges and lifts on symmetry of stance and weight bearing in hemiparetic individuals. Arch Phys Med Rehabil 2002;83: Objective: To determine the effect of shoe wedges and lifts on symmetry of stance and weight bearing in hemiparetic individuals. Design: Weight bearing on the paretic side was measured in patients with hemiparesis during quiet standing and in conditions of compelled weight shift. Setting: Free-standing acute inpatient rehabilitation hospital. Participants: Nine individuals with hemiparesis as a result of unilateral stroke who were able to stand for 3 to 5 minutes without assistance or rest, and satisfied other inclusion criteria. Interventions: Compelled shift of the body weight was induced with different shoe wedges (5, 7.5, 12.5 ) or shoe lifts (0.6, 0.9, 1.2cm), which extended under the entire shoe of the unaffected limb. Weight-bearing symmetry scores were used to characterize the symmetry of stance. Main Outcome Measures: Weight-bearing symmetry scores. Results: Without a shoe wedge or a shoe lift, weight-bearing symmetry was characterized by underloading of the paretic limb (39.90%.80% of body weight). Weight shift induced by shoe wedges or shoe lifts applied to the unaffected limb promoted improved symmetry of weight bearing and stance. A shoe wedge of 5 provided the most symmetrical weight distribution (51.44% 1.88% of body weight). Conclusion: Shoe wedges and shoe lifts under the unaffected limb induced compelled weight shift toward the paretic limb, resulting in improved symmetry of stance of individuals with mild hemiparesis. We suggest that improved symmetry of bipedal standing obtained with a shoe wedge or a shoe lift applied to the unaffected limb can help overcome the learned disuse of the affected limb. We further suggest that weight distribution induced by shoe wedges or shoe lifts may help in the treatment of ambulatory hemiparetic individuals with asymmetrical stance caused by unilateral stroke. Key Words: Hemiparesis; Rehabilitation; Weight bearing by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation From the Department of Physical Medicine and Rehabilitation, Rush-Presbyterian St. Luke s Medical Center, Chicago, IL (Rodriguez, Aruin); Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL (Aruin); and Marianjoy Rehabilitation Hospital, Wheaton, IL (Aruin). Accepted in revised form June 1, Supported in part by the National Center for Medical Rehabilitation Research, National Institutes of Health (grant no. HD-37141). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Alexander S. Aruin, PhD, Dept of Physical Therapy (MC 898), College of Applied Health Sciences, University of Illinois at Chicago, 1919 W Taylor St, Chicago, IL 60612, aaruin@uic.edu /02/ $35.00/0 doi: /apmr AS MANY AS 88% of individuals who have suffered an acute stroke have hemiparesis and poor voluntary control of movements, which result in disability. 1,2 Individuals with hemiparesis frequently bear most of their body weight through their uninvolved lower extremity, showing a distinct asymmetry of stance and weight bearing. 3-9 Symmetry of stance and weight bearing has been recognized as a predictor of the ability to ambulate. In a series of studies, 6,8,10-13 it was shown that achieving symmetry of stance and weight bearing is an important contributor to reaching goals of ambulation. Asymmetry of stance and weight bearing may be viewed as a consequence of a learned nonuse of the paretic side in hemiparetic poststroke individuals. Impaired proprioception, visuospatial deficits, and prolonged weakness might be among other factors that can trigger a learned disuse mechanism in hemiparetic individuals. Initially, an individual with hemiparesis might be unable or reluctant to bear weight on the paretic lower extremity when significant paresis exists. Subsequently, the hemiparetic individual may show continued weight-bearing asymmetry and foster future disuse of the paretic limb despite improved motor function in the lower extremity. This could limit the individual s capacity to regain full use of the paretic extremity even with some neurologic improvement. Animal studies and clinical trials in humans have shown that forced use and functional training of the paretic side substantiate the theory of neuroplasticity and contribute to improved function Several techniques are used to help individuals with hemiparesis to overcome learned nonuse of the affected side. One technique, the constraint-induced movement technique, has been particularly effective. This involves restraining the intact upper limb by using a sling for 2 weeks. It has been shown to improve the use of the affected upper extremity in individuals with hemiparesis. 17 This technique helps patients overcome the learned disuse mechanism by forcing them to use the affected upper extremity. Although this innovative approach can be effective in the rehabilitation of upper extremities, it cannot be used in gait rehabilitation for individuals with hemiparesis because restraint of the intact lower extremity will not allow ambulation. However, the concept of forced use of the affected side can be applied to the lower extremities as well. In retraining gait in patients with stroke, different methods are used to force use of the affected lower extremity. One method is to support a percentage of the patient s body weight by using a harness to lift the patient while walking on a treadmill. The use of partial weight bearing can result in improvement in the ability to walk when compared with gait training with full weight bearing. 18,19 Specifically, treadmill training with partial body weight support in nonambulatory hemiparetic patients was associated with a 150.4% increase in patients gait velocity, which is an improvement when compared with physiotherapy treatment based on the Bobath concept. 19 Another approach used to facilitate weight bearing through the affected lower limb is to place the unaffected lower extremity on a step. 9,20

2 WEIGHT-BEARING SYMMETRY, Rodriguez 479 This study sought to evaluate whether a simple device, the shoe wedge, can induce compelled weight shift on the paretic side, promoting a more symmetric stance, and can consequently be a potential tool for improving the ability to ambulate. It further evaluates the use of the shoe wedge versus the shoe lift in promoting stance and weight-bearing symmetry in hemiparetic individuals. METHODS Participants Subjects were selected from among patients referred by physicians in the stroke program at a rehabilitation hospital. Nine individuals (6 women, 3 men) with unilateral hemiparesis 2 to 8 weeks poststroke, ranging in age from 36 to 78 years, participated in the study. The inclusion criteria were a recent single unilateral cerebrovascular accident with demonstrated asymmetrical weight bearing, the ability to stand independently without an assistive device or an ankle-foot orthothis (AFO) for up to 5 minutes without rest, and the ability to understand and follow 2-step directions. Exclusion criteria were serious or unstable medical conditions; a history of other neurologic diseases, cognitive impairment, severe visual deficits, trauma, or orthopedic problems; or any other factors that might prevent participation in the experiments. Three subjects had right hemiparesis and 6 left hemiparesis. All had been independent in all activities before the stroke. Seven of the subjects had suffered ischemic strokes; 2 had suffered hemorrhagic strokes. Manual muscle testing was performed by using procedures described in the literature. 21 On gross manual muscle testing, 4 subjects had motor strength of 4/5 for hip flexors, knee extensors, dorsiflexors, and plantarflexors in the hemiparetic lower extremity; 5 had motor strength of 3/5 for the same muscles in the hemiparetic lower extremity. Sensation for both light touch and pinprick was impaired on the paretic side in 2 subjects. Apparatus Weight bearing of patients was assessed by using the Balance Master computerized force platform system. a The Balance Master consists of 2 force platforms connected to a computer, allowing independent measurement of vertical forces between the feet and the surface of the platforms. The percentage of the body weight carried by each lower extremity is obtained using computer programs, with the affected and the unaffected lower extremity measured independently. Procedure The subjects stood on the 2 force platforms with their feet positioned using the Balance Master protocol (fig 1). The medial malleolus of each foot was aligned with the transverse force platform line and the posterior border of each heel with the height-appropriate line. The subjects were instructed to stand upright, unassisted, with their arms at their sides and their eyes open looking straight ahead. The study was divided into 2 parts. In part 1, different shoe wedges were used; in part 2, different shoe lifts were used. Five series of weight-bearing measurements were performed in each part. In part 1, in the first and fifth series, weight bearing was measured while the subject stood on the force platforms before and after the placement of shoe wedges (series 1 and 5, respectively; fig 1). During the other 3 series of part 1 (series 2 4), the subjects were asked to stand on the force platforms with their unaffected limb on a small wedge applied beneath the entire foot. Three Fig 1. Schematic representation of the technique used. Subjects were positioned (A) on the Balance Master platforms. (B) Sized angled wedges or (C) lifts under the shoe of the stronger leg induced compelled shifts of the body weight toward the paretic limb. Weight bearing is in percentage of the body weight. different shoe wedges of cork covered with plastic were used, each having a different angle (5, 7.5, 12.5 ) (table 1). These angles were chosen based on a pilot study that showed that there was improvement of stance and weight-bearing symmetry in individuals with stroke when angled wedges of up to 13 were applied. The largest portion of the wedge was placed beneath the lateral portion of the shoe, placing the foot in a position of slight eversion. In part 2, 6 of the 9 subjects (from the same pool of subjects) participated in 5 additional measurements that evaluated the effect of shoe lifts versus shoe wedges. These shoe lifts were made of rubber, extending the full length of the shoe. Once again, weight bearing was measured before and after the placement of the shoe lift (series 6 and 10, respectively). In series 7, 8, and 9, the shoe lift, like the shoe wedge, was placed beneath the foot of the unaffected limb, with the subjects standing on the force platforms (table 1). Three different shoe lifts were used, each having a different height (0.6, 0.9, 1.2cm). These heights were chosen based on a previous study 13 showing that the application of lifts up to 1.3cm resulted in improvement in the symmetry of static posture of individuals with stroke. During the experiment, the subjects stood on the force platforms with their feet positioned according to the Balance Master protocol, with the shoe wedge or shoe lift applied beneath the foot of the unaffected limb. The subjects were required to stand unassisted during the measurement of weight distribution, which took approximately 5 minutes before rest. As the shoe wedges or shoe lifts were replaced for each series, it was ascertained that the proper position of the feet on the force platforms was maintained. To distract attention from the shoe wedge or the shoe lift, the subjects were required to look at the computer screen 1m in front of them. Three measurements were taken in each series. There were rest intervals of 1 minute between each series and 5 minutes between parts 1 and 2. Each part started and ended with measurement of weight bearing without the use of a shoe wedge or a shoe lift (series 1,

3 480 WEIGHT-BEARING SYMMETRY, Rodriguez Table 1: Description of Experimental Procedure Part 1 Part 2 Wedges Series Lifts Series No wedge 1 No lift 6 5 wedge 2 0.6cm wedge 3 0.9cm wedge 4 1.2cm 9 No wedge 5 No lift 10 NOTE. Wedges and lifts were applied under the unaffected limb. 5; series 6, 10). The sequence of the different angles (wedges) and heights (lifts) was randomized. No assistive device was used during the procedure. For safety, an experimenter always stood by the subjects, and a walker was available in front of the subjects in case they lost their balance. Data Processing Weight-bearing data on the weaker side were collected and averaged. Symmetry ratios reflecting the weight-bearing status of the subjects were calculated as weight bearing of the intact lower extremity divided by weight bearing of the paretic lower extremity. Repeated 1-way analysis of variance (ANOVA) measures were used to investigate the degree of change in weight bearing separately, in the series with the different wedge conditions (part 1), and in the series with the different lift conditions (part 2). Linear regression analysis of magnitudes of weight bearing on the affected side during use of different wedges and lifts was performed as well. Significance was set at P less than.05 in all cases. RESULTS The Effect of Shoe Wedges All subjects showed asymmetrical weight bearing with the paretic limb relatively unloaded while standing on the force platforms without a shoe wedge. The average weight bearing measured on the paretic side (no wedge situation) was 39.90%.80% of body weight. With the use of a shoe wedge on the unaffected limb, the symmetry of weight bearing improved (table 2). Single-factor ANOVA showed significant effects of weight shifting from the unaffected limb to the paretic limb for all 3 angles of the wedge (F 8,3 46.2, P.05). The symmetry of the weight bearing improved progressively with the increasing angle of the wedge, reaching 51.44% 1.88% of body weight for the 5 and 54.18% 1.87% for the 7.5 wedge (r.96, P.05) (fig 2). The difference between application of 5 and 7.5 angled wedges (F 8,1 2.5, P 0.1) was not statistically significant. The 12.5 wedge shifted body weight toward Fig 2. Changes in weight bearing with application of wedges (circles) and lifts (squares) are shown. Weight bearing was measured on the paretic side and is shown with standard error bars. Note changes in weight bearing with increase of angles of the wedges or size of the lifts. Linear regression equations are shown. The weightbearing scale is shown as percentage of overall body weight. the paretic leg more extensively (60.11% 2.19%), thereby creating a reversed asymmetrical condition in stance and weight bearing. Symmetry ratios for different angles of the wedge are represented in the table 3. When weight bearing with no wedge was measured for the second time (after the 3 series using the shoe wedges), there was a significant carryover effect, seen as a maintained increase in weight bearing on the paretic side. The average value of percentage of body weight measured on the paretic side after use of the shoe wedge (series 5) was significantly greater statistically than before use of the shoe wedge (series 1) (F 8,1 4.7, P.05). The Effect of Shoe Lifts In the second part of the study with shoe lifts, similar measures of the weight bearing on the paretic side were done on the 6 subjects who participated. When subjects stood with the unaffected limb on a shoe lift positioned on the surface of the force platform, the weight bearing became more symmetrical (table 2). Single-factor ANOVA showed significant weight shifting from the unaffected limb to the paretic limb for all 3 shoe lifts (F 5,3 6.18, P.05). The symmetry of the weight bearing improved progressively with the increasing Wedges Table 2: Weight Bearing on the Affected Side Weight Bearing on the Affected Side (% of Body Weight) Lifts Weight Bearing on the Affected Side (% of Body Weight) None None cm cm cm None* None* NOTE. Values are mean standard error. * The second measurements of weight bearing while standing with no wedge/lift conditions performed at the end of the tests. Table 3: Symmetry Ratios for Different Conditions of Compelled Weight Bearing Wedges Symmetry Ratio (R) Lifts Symmetry Ratio (R) None 1.50 None cm cm cm 1.15 NOTE. R is the symmetry ratio, reflecting the weight-bearing status of the subjects. It was calculated by using the equation R W I /W P where W I is weight bearing of the intact lower extremity and W P is weight bearing of the paretic lower extremity. Symmetry ratio of 1.0 reflects a 50/50 weight bearing.

4 WEIGHT-BEARING SYMMETRY, Rodriguez 481 height of the shoe lift, reaching 41.22% 2.09% of body weight for the 0.6cm and 46.27% 2.84% for the 0.9cm lifts, respectively (r.92, P.05) (fig 2). The use of the 1.2cm lift shifted the most body weight toward the paretic lower extremity (47.27% 2.19%). When weight bearing with no shoe lift was measured for the second time (after the 3 series using the shoe lifts), there was a carryover effect, which was seen as a maintained increase in weight bearing on the paretic side. The average value of percentage of body weight measured on the paretic side after use of the shoe lift (series 10) was slightly greater than before the use of the shoe lift (series 6). However, this increase was not statistically significant (F 5,1 1.16, P.20). Symmetry ratios for different lifts are represented in table 3. DISCUSSION Compelled Weight Shift in Improving Weight-Bearing Symmetry Individuals with hemiparesis frequently support most of their body weight on the uninvolved lower extremity, showing a distinct asymmetry. 3-7,9,20 It is quite possible that such an asymmetric stance, with the majority of weight bearing on the stronger side, can place the hemiparetic individual at a greater risk for falls by shifting the center of gravity to 1 side and thus creating instability. A small but reliable correlation between the number of falls and the standard deviation of weight distribution reported in the literature 22 supports this point. It is known that individuals with hemiparesis are actually able to bear more than 50% of their weight on their paretic lower extremity when requested to do so 5 and can increase their weight bearing through the weaker extremity, beyond what would be natural for them, during sit-to-stand maneuvers. 23 Therefore, with reeducation symmetrical stance and weight bearing can be achieved. Reeducating patients on how to attain symmetrical stance is important in improving balance control and is widely used in rehabilitation. 22,24-26 There are several techniques used for reeducating symmetrical stance. A shift of the body weight to the paretic side can be made voluntarily by the patient, can be made in response to cues from a physical therapist, or can be done with the help of a mechanical device. Although voluntary loading of the affected lower extremity can be successful, the effectiveness of such an approach is still a matter of debate. 27 In physical therapy, loading the affected lower extremity of a hemiparetic individual to improve the symmetry of static stance is considered helpful. 28,29 The Bobath technique uses a facilitation of weight bearing on the affected limb. In this technique, during the single stance phase of the affected limb, the physical therapist pushes the pelvis of the affected side down and forward, resulting in improvement of weight symmetry. 30 In a recent study 13 on the effect of compelled weight bearing on the symmetry of balance, it was shown that symmetry of stance in patients who have hemiparesis caused by stroke could be improved by shifting weight to the paretic side by adding a lift to the shoe on the unaffected lower limb. With the shoe lift, there was a shift of the center of gravity from the intact limb to the midline and a subsequent increase in stability. In a study in which individuals with hemiparesis received graded forward and backward perturbations while standing, it was shown that weight shifting to the weaker side induced by lifts on the stronger limb provides a more equal distribution of forces generated through both the affected and unaffected lower extremities. Consequently, there was a shift toward more normal levels of latency and strength response scores. 31 The results of our study show that compelled weight bearing can be induced not only with use of shoe lifts but also with shoe wedges on the unaffected side of individuals with mild hemiparesis. Although our results describe the short-term effect of weight shifting on symmetry of stance, the potential positive effect of such a technique can be supported by the results of a recent study, 13 in which a patient with chronic hemiparesis wore a shoe lift on the nonparetic limb for the duration of a 6-week physical therapy program. The outcome showed statistically significant improvement of symmetry of weight bearing, walking speed, and stride length. 13 Thus, the results of 2 studies taken together suggest that compelled weight shift on the paretic side might be used to preclude the learned nonuse syndrome in the rehabilitation of gait. Lift Sets Versus Angled Wedges In conditions without the shoe wedge or the shoe lift, all the subjects showed less weight bearing through their paretic limb, resulting in an asymmetrical stance. Similar results have been described in the literature. 3,4,6 There was a significant improvement in stance and weight-bearing symmetry with the use of a wedge or a lift on the unaffected side. Even the smallest wedge of 5 provided improvement of weight bearing on the paretic side from 39.90%.80% to 51.44% 1.88%; however, symmetry ratios improved more with the use of wedges as opposed to lifts (table 3). However, it is recognized that the shoe wedge may induce slight ankle eversion. Indeed, the application of an angled surface (a surface with different dimensions on each side), with the largest portion of the angle positioned at the lateral aspect of the foot, results in the inclination of the ankle joint in the frontal plane causing eversion. This might produce instability and result in injury. There is, however, normally 5.0 of subtalar eversion on passive range of motion, 32 and up to 7.2 of eversion of the subtalar joint occurs in 44% of the total gait cycle 33 and is considered normal. Thus, the use of wedges up to 7 should not be a source of potential harm to the user. Presently, different shoe and lower-extremity orthotics are used to correct gait patterns. In hemiparetic patients, the AFO is commonly used on the paretic limb for more ankle and knee stability during standing and walking. Thus, the shoe wedge can be used together with the AFO in retraining for gait in individuals with hemiparesis during the first 6 months poststroke when maximum recovery takes place. Application of the compelled weight-bearing technique creates an opportunity to combine several aspects of rehabilitation at an early stage. Our study was limited to the symmetry of weight bearing during static standing, involved a limited sample of individuals with mild hemiparesis, and was performed within a relatively short period of time. However, it is reasonable to expect that the shoe wedge would also be effective in promoting weightbearing symmetry when used during dynamic ambulation. Additional studies are needed to show that compelled weight bearing can improve locomotor patterns of the individuals with unilateral hemiparesis. CONCLUSION We have shown that a new approach in managing asymmetry of weight bearing of individuals with mild unilateral hemiparesis caused by stroke could provide some benefit tothe patients. The potential benefit is based on the ability of the patients to participate in a rehabilitation program involving standing and locomotion activities, with their weight equally distributed between the paretic and the nonaffected limb. Use of a shoe wedge or lift provides an innovative method of

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