GRF-AFO (FLOOR REACTION

ORTHOSIS)

Suman Kumar Panda, 1ST YEAR, MPO,

SVNIRTAR
 This presentation is
dedicated to Late Dr. A P J
Abdul Kalam
FRAFO?
or
GRAFO?
or
AFRO?
or
FRO?
The ground reaction AFO
(GRAFO) is a specific type of AFO
that is designed to harness the
ground reaction moment around
the ankle to increase the stability
of the knee in stance & also
capable of triplanar control of
the foot/ankle complex.
FRONTAL PLANE
CONTROL- Inversion &
Eversion
SAGITAL PLANE CONTROL
Dorsiflexion &
Plantarflexion
TRANSVERSE PLANE
CONTROL
-Rotations
HISTORY
-Dr. Jimmy Saltiel from
Israel (1969)
-In India Dr. P.K.Sethia & Dr.
S.C.Lakkad (1983)
-DRDO in collaboration with
Nijam Institute, Hyderabad
made the glassfibre-
composite FRO under the
leadership of Late Dr. APJ
Abdul Kalam.
PREREQUISITES:
-Appropriate alignment of the
foot & knee (knee & hip flexion
contracture not more than
10Degrees)
-Presence of some trunk balance
and/or the ability to use auxiliary
walking aids in the event of
diminished trunk balance.
 RECIPE

LAWS OF
PHYSICS
BIOMECHANI
CS

ORTHOTI
C DESIGN

BETTER
OUTCOME
LAWS OF PHYSICS
-Newtons 3rd Law

-1st Class Lever (Use of

the AFRO in Patients with
Cerebral Palsy, 1983,
Edwin D. Harrington et
al)
1ST CLASS LEVER
PRINCIPLE
NEWTONS 3rd LAW

To maintain the state

of equilibrium (knee
extension): for every
knee buckling
moment (action) the
pretibial shell must
provide an equal &
opposite moment
(reaction)
BIOMECHANICS
 Plantar flexionknee
extension couple

-In normal gait during 2nd half of the stance phase, stability of the
knee is maintained without quadriceps action by the mechanism
called PF/KE couple.
-GRF can be controlled by degree of ankle dorsiflexion (eccentric
contraction of Soleus thus controlling forward motion of tibia over
foot) during gait to increase or decrease the knee extension.
GRAFO DURING STANCE
3 ROCKERS (Fulcrum):
GRAFO DURING STANCE
ORTHOTIC DESIGN
 ANTERIOR
PARTS
TIBIAL
SHELL

The combination of these

three components allow the
plantarflexion-knee extension
couple (PF/KE) to occur,
causing a knee-extension
moment.
RIGID
ANKLE

FOOT PLATE
DETERMINANTS OF PF
ANGLE & LENGTH OF
PRETIBIAL SHELL
Theoretically, when the orthosis
is set in plantarflexion (5-
10Deg), the extension moment
is maximal but the forward
progression is at least partially
blocked.
-Determining the angle depends
on: sides of involvement &
quadriceps strength
Design Variants
 One piece: enclosing the back of the
lower calf, the shin, and the bottom of
the foot (Saltiel type ankle foot orthosis)

In June 1969, Jimmy

Saltiel described an ankle
foot orthosis which was
designed to stabilize the
paralyzed limb without
limiting knee movement.
Two piece (clam shell): same as the one
piece but with a removable anterior
shell

- Generally the
posterior section is
pulled first.
Rear opening: encloses the front
of the leg and top of the foot

- Not a popular
design
- Sometimes
recommended for
post -op Achilles
tendon repair
Composite AFO Design by
Dynamic Bracing Solutions
- Developed by Marmaduke Loke
and Jean-Paul Nielsen.
- The key to this design lies in
the material composition and
two flexible struts.
- This flexibility provides two
important elements: a dynamic
response to propel the limb
forward and a progressive
resisting force near the knee.
Texas TURBO AFO by Advanced
Orthopedic Designs
- Developed by Kevin
Matthews and his
associates, the key to this
design is the long
polypropylene strut that
runs from the medial arch
proximally and across the
tibia before running distally
and terminating near the
lateral malleoli.
Texas TURBO AFO by Advanced
Orthopedic Designs
- In contrast to the Composite AFO
Design, this strut provides maximum
rigidity and therefore can limit the
majority of ankle/foot triplanar motions.
- For this reason, Advanced Orthopedic
Designs recommends the Texas TURBO
AFO for PTTD, Achilles Tendonitis,
Arthritis, Plantar Fasciosis, and any
other diagnosis where ankle/foot motion
is contraindicated.
SM FRO (Indian Made)
- Standard Modular FRO
- Consists of three modular
pieces namely, foot
piece, lateral uprights
(glass reinforced PP) and
knee piece.
INDICATIONS:
Given in mainly neurological
related issues i.e.
-SPINA BIFIDA
-CP
-BRAIN INJURY
-SCI
-RFP
CONTRAINDICATIONS:
-Hip, knee, and/or ankle
flexion contractures
-Moderate to severe pes
valgus, tibial vara, genu
varum/valgum, genu
recurvation (ligament
laxicity)
WEARING SCHEDULE &
INSTRUCTION
1st Day: 1hr
2nd Day: 2hrs
3rd Day onwards increase an hour daily
-If any redness or callus we should
check the area of pressure
-Different heel height shoes should be
avoided
-Heel should be properly seated
Why this design is not popular in
India?
-Inadequate good quality Liners
-Skills for Vacuum plastic pulling
-Good quality Reinforced plastics
-Finishing tools
-Prescribing KAFOs increases
revenue
-Lack of practise knowledge
-No team work
 References & Sources
1. Perry J. Normal and pathologic gait. In: Hsu JD, Michael JW, Fisk JR, eds.
AAOS Atlas of Orthoses and Assistive Devices . 4th Ed. Philadelphia, PA:
Mosby Elsevier; 2008:61.
2. An Advanced Ground Reaction Design Ankle-Foot Orthosis to Improve
Gait and Balance in Individuals With Post-Stroke Hemiparesis: A Case
Series: Jennifer Hale et al
3. Case Study: Improving Knee Extension with Floor-Reaction Ankle-Foot
Orthoses in a Patient with Myelomeningocele and 20 Knee Flexion
Contractures: Donald Freeman et al
4. Use of the AFRO in Patients with Cerebral Palsy, 1983, Edwin D.
Harrington et al
5. Dynamic BracingSolutions
6. Advanced Orthopedic Designs, LLC
7. http://www.oandp.org/jpo/library/2013_01_042.asp
8. http://orthopedia.wikia.com/wiki/Ground_Reaction_AFO
9. http://www.oandplibrary.org/op/pdf/1983_04_034.pdf
A PIECE OF
PLASTIC IF
PROPERLY
FITTED, CAN DO
WONDERS
-Dr. A P J Abdul
Kalam