Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185

Contents lists available at ScienceDirect

Journal of the Mechanical Behavior of

Biomedical Materials
journal homepage: www.elsevier.com/locate/jmbbm

A review on the orthotics and prosthetics and the potential of kenaf T

composites as alternative materials for ankle-foot orthosis
Farah Syazwani Shahara, Mohamed Thariq Hameed Sultana,b,c,*, Seng Hua Leed,
Mohammad Jawaidb, Ain Umaira Md Shaha,b, Syafiqah Nur Azrie Safrib,
Praveena Nair Sivasankarane
a
Department of Aerospace Engineering, Faculty of Engineering, Universiti Putra Malaysia, 43400, UPM Serdang, Selangor, Malaysia
b
Laboratory of Biocomposite Technology, Institute of Tropical Forestry and Forest Products (INTROP), Universiti Putra Malaysia, 43400, UPM Serdang, Selangor,
Malaysia
c
Aerospace Malaysia Innovation Centre (944751-A), Prime Minister's Department, MIGHT Partnership Hub, Jalan Impact, 63000, Cyberjaya, Selangor Darul Ehsan,
Malaysia
d
Laboratory of Biopolymer and Derivatives, Institute of Tropical Forestry and Forest Products (INTROP), Universiti Putra Malaysia, 43400, UPM Serdang, Selangor,
Malaysia
e
School of Engineering, KDU University College Sdn Bhd (76997-T), Utropolis Glenmarie Campus, Jalan Kontraktor U1/14, Seksyen U1, 40150, Shah Alam, Selangor,
Malaysia

A R T I C LE I N FO A B S T R A C T

Keywords: Since ancient Egypt, orthosis was generally made from wood and then later replaced with metal and leather
Ankle-foot orthosis which are either heavy, bulky, or thick decreasing comfort among the wearers. After the age of revolution, the
Kenaf composite manufacturing of products using plastics and carbon composites started to spread due to its low cost and form-
Orthosis history fitting feature whereas carbon composite were due to its high strength/stiffness to weight ratio. Both plastic and
carbon composite has been widely applied into medical devices such as the orthosis and prosthesis. However,
carbon composite is also quite expensive, making it the less likely material to be used as an Ankle-Foot Orthosis
(AFO) material whereas plastics has low strength. Kenaf composite has a high potential in replacing all the
current materials due to its flexibility in controlling the strength to weight ratio properties, cost-effectiveness,
abundance of raw materials, and biocompatibility. The aim of this review paper is to discuss on the possibility of
using kenaf composite as an alternative material to fabricate orthotics and prosthetics. The discussion will be on
the development of orthosis since ancient Egypt until current era, the existing AFO materials, the problems
caused by these materials, and the possibility of using a Kenaf fiber composite as a replacement of the current
materials. The results show that Kenaf composite has the potential to be used for fabricating an AFO due to its
tensile strength which is almost similar to polypropylene's (PP) tensile strength, and the cheap raw material
compared to other type of materials.

1. Introduction
Orthosis can be defined as an artificial external assistive device
which supports the limbs or spine to prevent or assist any movement
made by the patients. As for prosthesis, it can be defined as an artificial
body part which completely replaces the missing body part.
The similarities between both orthotic devices (orthosis) and pros-
thetic devices (prosthesis) were that both were designed to support a
specific part of the body to enable the patient to move or functioned
properly. Both orthotics and prosthetics share the same ideal specifi-
cation, which are light, high stiffness to resist shear stress, high tensile
and compressive strength, high durability under impact, cheap, and
easy to don on or off (Berry, 1981).
The major differences between an orthotic devices and prosthetic
devices is that the prosthetic devices are used to replace the limb
completely (Nurhanisah et al., 2018) whereas orthotics devices are used
to enhance the functionality of the limbs (Kuettel, 2016) which has any
deficiencies or deformities making it unable to function properly.
From the previous researches, it was found that the amount of or-
thotic research articles produced are significantly less compared to
prosthetics research articles (Miro et al., 2013). This shows that or-
thotics has a bigger opportunity for growth in research. There are a lot

*
Corresponding author. Department of Aerospace Engineering, Faculty of Engineering, Universiti Putra Malaysia, 43400, UPM Serdang, Selangor, Malaysia.
E-mail address: thariq@upm.edu.my (M.T. Hameed Sultan).

https://doi.org/10.1016/j.jmbbm.2019.07.020
Received 28 June 2019; Received in revised form 19 July 2019; Accepted 20 July 2019
Available online 24 July 2019
1751-6161/ © 2019 Elsevier Ltd. All rights reserved.
F.S. Shahar, et al.
of possibilities that had not been discovered in this specific area. In
addition, with the current technology development, there are a lot of
areas that can be explored in order to improve the existing orthosis,
especially its materials. Thus, this review will focus more on orthotic
devices instead of the prosthetic devices.
1.1. Orthotics and prosthetics history (ancient history – 3000 BC until 500
AD)
Orthotics and prosthetic history could be traced back since the an-
cient era of Egypt dated roughly around 5000 years ago as the art of
splint and brace making has been applied on a fractured limbs ex-
cavated in the 20th century by the Hearst Egyptian Expedition of
University of California headed by Dr. George A. Reisner (Elliott Smith,
1908; SIR GRAFTON ELLIOT SMITH, 1936). These splints were the
oldest splints discovered throughout history and it was reported to
come from the 5th Egyptian Dynasty which is equivalent to 2750–2625
B.C. Instead of just fulfilling their main aim of collecting the splints for
the museum exhibits, the head of that particular institution gave per-
mission for Dr. Reisner to make a scientific investigation on the ex-
cavated remains and splints (Elliott Smith, 1908). Sir Grafton Elliot
Smith was also given the opportunity to examine the ancient splints
which finally lead to the discovery of the surgical history (Elliott Smith,
1908; SIR GRAFTON ELLIOT SMITH, 1936). The splints and braces
were used to give support and protect fractured or broken bones after
undergoing any surgery.
The splints were placed in the Cairo museum for five years as part of
the museum exhibition before it was taken to be examined by Dr.
Reisner and his team. It was found that the splints were still attached to
a young girl's broken limb around the age of 14 years old. From further
investigation, the splints were used to hold a fractured femur of the
female mummy. The four splints were made from a rough, slender
wood strip, and wrapped up with the linen bandage before being fixed
to the limb.
Another notable discovery was achieved by Brier and his team in
2015 had also proves the existence of prosthesis since the ancient
Egyptian era by using the radiologic examination of two mummies
(Brier et al., 2015). The mummies were brought to the Albany Institute
of History and Art 100 years ago and had remained unstudied until
1989.
From the 1989 investigation, the researchers found a prosthetic toe
from one of the mummies which was identified as Ankhefenmut.
However, due to the limitation of the CT scans technology at that time,
the prosthetic toe was believed to be made of ceramics due to the dif-
ference in scan density. It was unclear whether the prosthesis was used
as a functional element or merely intended to make Ankhefenmut
whole for the next world entry.
Thus, with the current CT scan analysis, a detailed image of the
artificial toe can be retrieved. It was found that the part which was
attached to the foot was made of ceramic, whereas the part which re-
presents the missing toe seems to be thin and made with resin coated
wood. This Albany toe was compared with the other two prosthetic toes
placed in the British Museum to figure out whether the Albany toe was
made to be used functionally or aesthetically.
The functionality of the artificial toe was further clarified with the
discovery of two other prosthetic toe which is now located in the British
Museum. The two toes have been in the museum since 1981. The first
toe was made from plaster coated linen, and has been painted to appear
more lifelike (Brier et al., 2015; Falder et al., 2003). The coating on the
toe was well preserved, but there is a sign of wear as seen from the thin
coating at the surface of the lower part of the prosthesis indicating its
everyday usage. Thus, this has further proved that it is a working
prosthesis and it is not only used as cosmetic restoration for the after-
life.
The second Egyptian toe was found in 1998 was excavated from
Tomb 95 located on the west bank of Nile, Egypt. Unlike the first toe, it
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Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
was found still attached to its owner. It was made from three wood
pieces and held together by seven leather laces. The largest wood piece
was carved to resemble a toe which then tied to the other two small
plates and was kept in place with a textile extended across the plates
and around the plates (Brier et al., 2015; Nerlich et al., 2000).
From the comparison of the three prosthetics, Brier et al. concluded
that the Albany toe was made in order to make the deceased whole in
preparation for the next life. They stated that the ceramic component
used to make the toe was not suitable for daily use and fragile when
compared to the other two prosthesis from the British Museum.
Around 1000 BC to 476 AD, when the Greco-Roman World was still
thriving, medical practices around this period has a significant influ-
ence towards modern medicine. Many famous physicians were born
during this time period such as Hippocrates, Herophilos, Dioscorides,
and Galen of Pergamon. The most outstanding physician which had
influenced the development of medical practices was Hippocrates,
which also known as the “Father of medicine”. Around 460 BC until 370
BC, Hippocrates had used splints made of leather and wood to fix a
fractured tibia (Bisaccia et al., 2016). The splints were made of two
leather rings where one of the rings were placed around the knee while
the other were placed on the ankle. Both rings were connected to each
other via a long rod made of cherry wood. The rods were placed lat-
erally with respect to the ankle and knee in order to allow unrestricted
movement of the ankle and give some skin exposure for easier inspec-
tion when needed.
After the Greco-Roman World period, the world transitioned into
the medieval period, also well known as the Dark Ages at its early stage.
The medieval period begins after the fall of Roman Empire around 476
until it ends around 1500. There was no significant progress or devel-
opment of medical practices occur after the fall of the Roman Empire
until the Renaissance era came. During this period, war has become
more prevalent and the decline of population also had affected the
growth of medical practice during that era. However, fractures and
broken bones has become a common issue due to the war. Thus, at that
time period, fractures and broken bones were treated with a plaster
mould or splint. The plaster mould was made from flour and egg whites.
Instead of the development in medical application, this era more fo-
cusses on the manufacturing of splint armours. These was made by
attaching metal splints to a leather backing. Most of the modern or-
thosis were designed according to these armours which functioned as
body protection and in some cases for body support.
1.2. Orthotics and prosthetics history (modern history – 1501 AD until
present)
After the medieval period, the world enters the renaissance era
which marks as the transition of the medieval period into modernity.
This era started around the year of 1500 until 1800. During the mid to
late 1500s, a French surgeon named Ambroise Pare had introduced
modern amputation and then created prosthetic devices which includes
adjustable harness, knee lock control, and other engineering features
that are being used in today's devices.
His major motivation in creating prosthesis was in order to help the
soldiers that had lost their limbs during the war. During his service, he
found out that most soldiers would rather commit suicide instead of
living without limbs. Thus, with his knowledge and expertise as an
anatomist, he created artificial limbs that could work as good as a
biological limb. His most notable design was a mechanical hand which
was operated with multiple catches and springs, worn by French Army
Captain during battle (Hernigou, 2013). The captain exclaimed that the
mechanical hand was able to work exactly like a real hand. The pro-
totype of the mechanical hand was made from iron or steel. Other than
prosthetics, Ambroise Pare also invented a perforated steel orthosis or
better known as the metal corset which could help in correcting the
spinal column structure or scoliosis. The corset was made from either
iron or steel with a leather lining at its edge. The orthosis was designed
F.S. Shahar, et al.
with several holes on it to reduce the weight of orthosis. He also
highlighted that there was a high rate of children with club foot borne
during that time period. Thus, he introduced an orthosis for club foot
correction by using metal, wood, and fabric (Markatos et al., 2015).
In 1876, Hugh Owen Thomas invented the Thomas splint which is
used to treat the deformities at the lower limb (Gray and Santy-
Tomlinson, 2018). It was a simple design with the main objective of
immobilizing the lower limb. The splint was made from a padded metal
ring which is attached to a leather that was attached to an angled bar
that extends from the groin to below the foot on both side of the leg.
After the renaissance era, the development of orthosis and pros-
thesis had a rapid change in material development. Even though the
basic design of both orthosis and prosthesis does not change much since
the ancient times, there is quite a significant change towards the ma-
terials used due to the age of industrialisation. Unlike in the previous
eras, the industrialisation age was able to give more possibilities in the
manufacturing orthosis and prosthesis due to invention of machines.
In the 1960's, Yates and Lehneis had written the first article about
replacing metal orthosis with the thermoformed plastics (Shamp,
1983). At the start of its introduction as an orthotic material replace-
ment, a lot of the researchers debated and kept on comparing the
conventional metal to the thermoformed plastics. However, after some
investigation, it was found that plastic has more advantages compared
to metal. It is light, hygienic, form-fitting, and noise-free. Unlike metal
orthoses, plastic orthoses are thin enough to be worn within the user's
clothes, thus increasing the cosmetic value. Since then, thermoformed
plastics has started to dominate the orthotic and prosthetic field.
In 1966, carbon fiber composites had its first experimental testing
made by Nigel Ring (Klasson, 1995). The composites were well known
as a material which has a high strength to weight ratio. In other words,
it has the strength of a metal and the weight of plastic depending on
how it was manufactured and designed. Thus, carbon composites have
become one of the most favourable material to be used aside from
plastics.
As the time passes, many experts start to define splints and braces as
one of the orthotic devices. Orthotics can be defined as a branch of the
medical field where it focusses on the design, fabricating, and fitting of
an orthosis. The definition of an orthosis is an external device which is
used as a support in order to fix a certain part of the body by applying
some force onto it, to keep it from moving and cause extra harm. It also
provides support for body movement when there is any muscle defor-
mity and nerve weakness at certain body parts.
After several centuries has passed, orthotic and prosthetic devices
has become more user friendly and aesthetically pleasing. The leather
straps has been changed into Velcro straps which is much smoother and
reduce skin irritation. The steel splints or braces has been changed into
a lighter material such as aluminium or carbon fiber. Finally, for lower
limbs orthosis which were using the heavy and bulky shoes as the foot
support has also been replaced with lighter material such as poly-
propylene and carbon fiber. Fig. 1 shows the timeline summary of or-
thosis development since ancient civilization.
However, due to the limitations or problems caused by these ex-
isting materials, a new material will be put into consideration. Thus,
this review paper is intended to discuss further on the existing orthosis
materials, the advantages and disadvantages of these materials, and the
possibility of using a natural fiber composite as a replacement of the
current materials.
2. Orthotic devices
Orthotic devices (Orthosis) can be divided into three types based on
the anatomical structure of the human body which are the spinal or-
thosis, upper limb orthosis, and lower limb orthosis. Spinal orthosis is a
back brace that was designed to support the spine and keeps it place to
reduce the chances of the spine from curving as the patients gets older
such as scoliosis. However, the most significant indication for this
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Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
orthosis is usually in the spine's traumatic injury management.
Upper limb orthosis can be applied to five upper extremity regions
which are shoulder, arm, elbow, wrist, and hand. Some example of
cases which utilises upper limb orthosis are Hemiplegia, Rheumatoid
Arthritis, and burns.
The lower limb orthosis is divided into five types based on which
part it supports or enclosed. The types that had been identified are Foot
orthosis (FO) (Clark et al., 2006), Ankle-Foot Orthosis (AFO) (Alam
et al., 2014; Polliack et al., 2001), Knee orthosis (KO) (Alam et al.,
2014; Iijima et al., 2014), Knee-Ankle-Foot orthosis (KAFO) (Polliack
et al., 2001), and finally Hip-Knee-Ankle-Foot orthosis (HKAFO)
(Polliack et al., 2001).
Foot orthosis (FO) is known as shoe inserts, arch supports, or insoles
is a device which contoured the whole foot and fix the abnormal motion
or position of a foot. This orthosis usually designed to fit inside the
footwear to control any abnormal foot function or reduce the pain areas
around the foot. It acts as cushion and helps in stabilising the foot to
improve the gait movement or reduce any pain experienced by the foot.
Some medical cases that uses FO includes arthritis, plantar fasciitis, shin
splints, tarsal tunnel syndrome, and flat feet.
Knee orthosis (KO) covers the area around above and below knee
joint. KO are more commonly known as a knee brace. This orthosis
functions as a support or helps in alignment of the knee. It helps reduces
pain in cases such as osteoarthritis. In some cases, it helps in preventing
the knee from the instability during flexion or extension. KO are also
popular among athletes whereby they used the orthosis as a way to stay
active and enhance the position and movement of the knee while at the
same time reducing the pain or pressure exerted towards the knee
joints.
Knee-Ankle-Foot Orthosis (KAFO) focuses its function on the
movement of joints of the ankle and knee. It is designed to provide
support to the knee, ankle, and foot while aligning the joints to com-
pensate the muscle weakness during gait movement. During stance
phase, the orthosis will lock the knee in place ensuring that the user is
able to stand or ambulate safely without buckling. The orthosis spans
from the thigh up to the foot and it is usually prescribed for patients
with Rickets, Bow Leg, and Knocked Kneed.
Hip-Knee-Ankle-Foot Orthosis (HKAFO) is actually a combination of
two KAFOs which link to the hip by a pelvic band. Unlike KAFO which
only provides locked knee joint, HKAFO also provide locked hip joints
for stability in traverse and sagittal plane. The hip joint and pelvic
section provides hip movements such as from front to back, side to side,
rotation while minimizing the risk of the hips from dislocating. This
orthosis usually indicated for cerebral palsy, paralysis, or Duschenne
Muscular Dystrophy.
Finally, an Ankle-Foot Orthosis (AFO) was designed to cover from
the foot up to below the knee. It is intended to control the movement
and alignment of the ankle, and also compensate for the nerve or
muscle weakness around the foot. Due to the common problem of foot
drop among Malaysian, this paper review will be directed towards the
ankle-foot orthosis (AFO) research. There are two main categories of
the AFO designs which are articulated (jointed, flexible around the
heel) and non-articulated (rigid). For an articulated AFO, its joint/
hinges assume the function of the ankle joint and helps in lifting the
foot up during the swing phase in cases such as foot drop. As for a non-
articulated AFO, it restrains ankle movement in cases such as broken or
fractured bones. This paper will particularly discuss on AFO for foot
drop due to its simple biomechanics and material selection compared to
other orthosis.
2.1. Drop foot/foot drop
Drop foot which is also known as foot drop is an anatomical pro-
blem where there is a weakness or paralysis at the anterior portion of
muscles of the lower leg (Liu et al., 2013). It is characterised as the
difficulty in lifting the front part of the foot, making it drag on the
F.S. Shahar, et al.
Fig. 1. Summary of the orthosis material's development timeline.
ground when walking. This problem in gait movement may be tem-
porary or permanent depending on the main cause of the foot drop.
Foot drop may be caused by several different factors which relates
to the weakness or paralysis of the foot muscles. Some of the factors are
(Graham, 2014):
i. Nerve injuries: The lifting of the foot is mainly controlled by the
peroneal nerve which is a part of the peripheral nervous system.
Any injury on this specific nerve could cause an inability to bend or
lift the foot upward at the ankle. Some examples are sports injuries,
diabetes, large amount of weight loss, or long hours of sitting cross-
legged or squatting.
ii. Brain or spinal cord disorders: Diseases or disorders which dis-
rupt the normal brain or spinal cords could also cause foot drop
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Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
such as the Parkinson's disease.
iii. Muscle or nerve disorders: There are various kind of muscle or
nerve disorders that could cause foot drop such as stroke, cerebral
palsy, polio, or Charcot-Marie-Tooth disease.
The symptoms of a foot drop are:
i. Difficult or unable to lift the foot
ii. Foot drags on the ground while walking
iii. Thigh is raising higher than normal to avoid dragging (high step-
ping gait)
iv. The foot gives out pain or feels numb when moving or lifting
The gait cycle is a combination of two primary walking phase which
F.S. Shahar, et al.
are the stance phase and swing phase. The combination the stance
phase and swing phase can also be divided into eight phases. It starts
with the initial contact, followed by loading response, mid-stance,
terminal stance, and end with pre swing in the stance phase. After that
it continued with initial swing, mid swing, and finally late swing re-
spectively in the swing phase (Bonnefoy-Mazure and Armand, 2015).
In a normal gait cycle, during the initial contact, the foot will in-
itially be in contact with the ground, thus known as foot strike. When
foot started to leave the ground and transitions into the swing phase, it
is known as foot off. Once the gait movement enters the swing phase,
the foot will never be in contact with the ground a certain period of
time. During this phase, all the foot portions will be in a forward mo-
tion.
However, in foot drop gait cycle, the movement of the foot will a bit
more different during the foot strike, foot off, and swing phase. In initial
contact, instead of the normal heel-toe foot strike, the front foot will
either slap or drag on the ground or completely planted on the ground.
As it transitions into the terminal contact, the foot will be unable to
support their body weight causing more pressure to be placed on the
leg. Once it enters the swing phase, the knee will be flexed more than
normal to accommodate the inability to dorsiflex and resembles the gait
movement when climbing the stairs. This particular movement is also
known as the high stepping gait.
The treatment for foot drop may differ depending on the cause of
the foot drop. Some of the treatment includes exercises to strengthen
the muscles and maintain the joint motion of the foot to improve the
gait. Another treatment was by stimulating the peroneal nerve with
electric during footfall which also known as Functional Electrical
Stimulations (FES). In worst cases, the patients has to undergo a surgery
to repair or decompress the damaged nerve. Finally, for mild cases of
foot drop, doctors usually treat the disability by using the Ankle-Foot
Orthosis. This device will be able to help in correcting the patients’ gait
either temporarily or permanently depending on the severity of the foot
drop. It could help these patients to walk better and safely. The orthosis
will be fitted to the foot to hold the foot in a normal position.
2.2. ANKLE-FOOT orthosis (AFO)
In foot drop cases, an Ankle-Foot Orthosis (AFO) is a device or
product which help in supporting and controlling the position and
motion of the ankle while walking. It compensates the weakness or
deformities of the peroneal nerve or muscle by supporting and stabi-
lising the foot and ankle during the swing phase gait in the gait cycle.
For foot drop treatment, an AFO with 90° foot drop stop was usually
assigned to the patients and designed using a variety of materials. It was
assigned when the plantar flexors are normal but dorsiflexors are weak
(plantar flexion stops at the neutral position of 90°) or vice versa.
Generally, AFO was constructed in the shape of an “L”, where the
horizontal portion was placed under the foot and the vertical portion
was placed behind the calf. AFO can be divided into two types which
are articulated AFO (has jointed ankle to provide control) and non-ar-
ticulated AFO (rigid).
The articulated AFO can be defined as a jointed AFO where the
jointed part at the ankle was joined mechanically and has the flexibility
to move the ankle upwards or downwards during walking. As for the
non-articulated AFO, it is a solid or rigid AFO where it supports the foot
and ankle in one place and does not allow any movement unlike the
articulated AFO. Both types of AFO design has its own advantages and
disadvantages.
For an articulated AFO, the biggest advantage of this design is its
flexibility in letting the movement of ankles for dorsiflexion and plan-
tarflexion (Alam et al., 2014). It does not limit the gait movement of its
user and has higher stability and better gait movement compared to the
non-articulated AFO. In addition, the movement of climbing, walking
up and down the hill, walking and crouching appeared more natural.
However, the disadvantage of this type of design is that it is sometimes
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Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
too heavy, bulky, and hard to be concealed inside the user's clothes.
Furthermore, sometimes this type of this design promotes excessive
sweating around the enclosed area which decreases the user's com-
fortability and promotes skin irritation and oedema. The materials that
was usually used for this design are metal, leather, and carbon fiber
composite.
As for the non-articulated AFO, this design is a direct opposite of the
articulated AFO. The non-articulated design was designed with a fixed
stiffness so that the patient would not be able to move their ankle while
walking (Alam et al., 2014). Most of the AFOs using this type of design
were made from thermoplastics. Thus, this type of AFO are usually
light, aesthetically pleasing, and can be concealed inside the user's
clothes. However, non-articulated AFO does not allow any movement
around the ankle, causing the gait movement of the users seem un-
natural and limited. The stability of their movements was also taken
away. Due to high contact area with the skin, irritations or rashes are
much worse compared to an articulated AFO when it is used for a long
period of time.
3. Fabrication process of ankle-foot orthosis (AFO)
The primitive orthosis was generally created as a simple device
made from wood and leather. As the years goes by, the world enters
industrial revolution era where many new machines, technologies, and
techniques were invented, thus making manufacturing using metal
spreads to every field including the orthotics field (Mulgaonkar et al.,
2008). Orthotics field began to evolve rapidly as it enters the era of
modernity and its designs are becoming more functional, user-friendly,
and eco-friendly.
As the developments made in material science has become more
significant, new materials which were made into composites such as
carbon composites, and plastics due to 3D printing, has become one of
the most widely used application for consideration of the orthosis de-
sign material (Takhakh A and Abbas S, 2018).
Currently, AFOs can be made by using one of the methods stated
below (Munguia and Dalgarno, 2013):
i. Thermoforming polymer sheets around a plaster cast impression
ii. Pre-preg carbon fiber sheet layup using plaster cast base as re-
ference surface
iii. 3D printing
3.1. Thermoforming polymer sheets around plaster cast impression
Thermoforming an AFO usually used a thermoplastic such as poly-
propylene (PP) as its material. A significant property of a thermoplastic
was that the materials will always softens when heated. Due to this
factor, it is easier to mould a PP into a desired orthosis design/shape.
Fig. 2 shows the process in fabrication of a thermoformed AFO.
In thermoforming, there are four factors which are significant in
ensuring a successful operation, which are:
i. Heating temperature
The heating temperature depends on the type of polymer used,
where a homopolymer must be heated with temperature around 175 °C
until 180 °C whereas a copolymer must be heated with temperature
around 165 °C until 170 °C.
ii. Heating duration
Next, the heating duration of the PP sheet will vary according to the
thickness of the sheet. It is recommended that the PP thickness is
around 3 mm–5 mm for an orthosis depending on the patient's weight.
The standard estimation for the heating duration can be calculated by,
F.S. Shahar, et al.
Fig. 2. The steps involve in the typical thermoforming process (Munguia and Dalgarno, 2013).
Fig. 3. Fabrication process of the carbon fiber AFO (Munguia and Dalgarno, 2013; FIORGENTZ - Orthopädietechnik mit Systemen, 2019).
Heating duration = (5 min× t) + 10 min
Where.
t = thickness of PP sheets.
As an example, for a 3 mm sheets,
Heating duration=(5 min× t) + 10 min
Heating duration=(5 minutes × 3) + 10 minutes = 25 minutes
iii. Temperature homogeneity in the oven
Some ovens may not heat evenly and has a problem in heat dis-
tribution. It is important to ensure that the heats spread evenly in the
oven to get a good quality of the thermoformed sheets.
iv. Teflon lining condition
While the PP sheets was heating in the oven, it is important to
Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
(1) prevent the sheets from sticking by covering the oven tray with a Teflon
sheet. The Teflon sheet must be free from any defects and clean to
prevent damage to the PP sheet.
3.2. Pre-Preg carbon fiber sheet layup using plaster cast base as surface
reference
The meaning of pre-preg is that it is a technology or technique in
which reinforced fiber of the composite materials is pre-impregnated
with a resin/polymer matrix in a certain ratio. This technology made
the manufacturing of light, high-quality, and strong orthoses was made
possible. Most research indicated that using a woven composite is more
recommended compared to a unidirectional composite to fabricate an
orthosis due to its higher strength and stiffness, which could help in
supporting lower limb. The matrix will usually be coupled with an
epoxy resin instead of other type of resins such as phenolic for its
fabrication since an orthosis does not require high temperature re-
sistance.
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F.S. Shahar, et al.
There are two major reason using a pre-preg carbon fiber in orthosis
fabrication which are the performance and the cost. The pre-preg can
be easily processed which results in lower fabrication cost, reduced
energy consumption, and could also control the amount of fiber content
used in fabrication. Furthermore, a pre-preg carbon fiber has good fa-
tigue, tensile, and stiffness which is highly required for a safer and
strong orthosis. Pre-preg could also resist corrosion which may harm
the patient's health when using the orthosis. Fig. 3 shows the general
fabrication process of a pre-preg carbon fiber AFO.
The major difference between the plastic AFO fabrication process
and the carbon fiber based AFO is that the carbon fiber AFO were
fabricated by laying several layers of sheets with different orientation
around the plaster cast until achieving the desired thickness instead of
thermoforming the sheets with a prescribed thickness (Zou et al., 2014).
3.3. 3D printing
Unlike thermoforming PP sheets and laying up pre-preg composites
which has been used for several decades, 3D printing technique is fairly
new in the orthotics field due to limited material availability and the
materials’ low strength compared to its traditionally manufactured
parts. Thus, currently there is an extensive research being carried out in
order to improve this technique which may be useful in reducing the
time taken for an orthosis manufacturing.
3D printing which is also known as additive manufacturing is a
technique in which a digital model was created to make a solid 3D
model. In 3D printing, the digital model of an orthosis can be obtained
by using the CAD/CAM technology to create a 3D model from the
ground up with a 3D modelling software or from the data generated
from a 3D scanner. After that, the prototype will be printed layer by
layer by using the 3D printer. Currently, orthosis are mostly printed
using plastic materials such as polypropylene and ABS which are
available in a filament form. Fig. 4 shows the process of fabrication
using 3D printing.
4. Orthosis existing materials
Throughout the years, AFO materials has evolved gradually starting
from wood, metal and leather, plastic, and carbon fiber composite re-
spectively as shown in Fig. 5. AFO is an orthosis which supports or
protects the ankle and foot of a user while also repairing the user's gait
movement and stability. An AFO's most ideal requirements are:
i. Strong enough to provide support
ii. Flexible to provide comfort while walking
iii. Breathable to reduce or prevent excessive sweating
iv. Lightweight to reduce energy exerted while walking
v. Thin orthosis to enhance aesthetic looks and easier fitting into
clothes
Fig. 4. General fabrication process of AFO by using 3D printing.
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Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
vi. Easily mouldable for custom made orthosis
The following sub-sections will discuss on the materials that has
been used and researched for the past several years since orthosis has
been introduced until now.
4.1. Wood orthosis
Wood orthosis has existed since the ancient civilization era. The
advantages of using wood for an orthosis fabrication are due to its re-
newability, machinability, good strength to weight ratio, does not rust,
and aesthetically pleasing. However, the downside is that the properties
of wood are highly variable. The variability of wood mechanical
properties could be affected by its species, moisture content, or even the
orientation of the load against the grain. The mechanical properties of
the wood are comprised of tension, compression, flexure, and finally
shrinkage and swelling.
Generally, the density of woods are ranged from 160 kg/m3
(Borrega and Gibson, 2015), (The Engineering ToolBox., 2017) up to
1350 kg/m3 (The Engineering ToolBox., 2017), (Naylor, 2014) where
the lightest wood was Balsa wood and the densest or heaviest wood is
the lignum vitae. The most common type of wood that has been used
were the bark of the cork of an oak tree or balsa wood (Edelstein and
Bruckner, 2002). It was estimated that the Balsa wood density was
recorded around ± 160 kg/m3 (Green et al., 1999; Newaz et al., 2016;
Pertiwi et al., 2017) whereas in comparison an oak wood density
ranged around 600 kg/m3 until 900 kg/m3 (Green et al., 1999; Newaz
et al., 2016; Pertiwi et al., 2017), (Green et al., 1999; Newaz et al.,
2016; Pertiwi et al., 2017). In other word, a Balsa wood is much lighter
than a cork of the oak tree. Thus, Balsa wood were sometimes used as a
shoe lifts or arch supports due to its light weight.
In order to ensure safety and stability, an orthosis needs to have a
good tensile strength, compressive strength, and flexural strength. Both
tensile strength and compressive strength of wood can be divided into
two type, which is the strength along the grain, and the strength per-
pendicular to the grain. Its strength is the strongest when tension was
exerted along the grain. It was estimated that the range for the wood
tensile strength along the grain is around 1.9 MPa (Kosipo wood)
(MatWeb. Tropical Kosipo W, 2019) to 161 MPa (European Ash wood)
(MatWeb, 2558). As for the compressive strength along the grain, it was
estimated that the value of the strength are around 20 MPa (Poplar
wood) (Green et al., 1999; MatWeb, 2942) up to 44 MPa (Hickory
wood) (Green et al., 1999; MatWeb, 2019a, 2019b). The flexural
strength of wood are ranging from 19 MPa (Green et al., 1999; MatWeb,
2019c) (Balsa wood) up to 179 MPa (Ebony wood) (Green et al., 1999;
MatWeb, 2019d). Generally, wood has a low modulus of elasticity. The
modulus of elasticity of wood are ranging approximately from
5800 MPa (Cedar wood) (Green et al., 1999; MatWeb, 2668) up to
12,000 MPa (Hickory wood) (Green et al., 1999; Meier, 2003; MatWeb,
F.S. Shahar, et al.
Fig. 5. The evolution of AFO materials.
2868; MatWeb, 2019e). Thus, depending on the wood species and its
mechanical strength, the material may or may not be suitable to be used
as an orthosis material. The selection of wood material highly depen-
dent on the type of orthosis that will be developed.
As discussed previously, the earliest wood orthosis that was ever
made, was discovered being worn by a young female Egyptian mummy.
The splints were made from slender tree barks and wrapped with linen
clothes around the mummy's legs to treat her fractured femur (Elliott
Smith, 1908). Another wooden orthosis that has been kept in historical
records was the wooden splints made by Almiron M. Day during Civil
War in 1850's (Mickelson, 2015; Bennington Museum, 2505). The
splints that he made was adjustable with the inclusion of wooden knobs
below the foot plate. There were three clothe straps to hold a leg in
place, and one clothe strap to hold the foot plate in a right-angled de-
gree. Finally, in 1942, Charles Eames invented the Eames Splints and
presented them to the US Navy during the 2nd World War (Owen, 1998;
Eames, 1942). The Eames splints were made of plywood, which made
the splints to be lightweight. Furthermore, it was made in modular
form, so that it can be manufactured and transported in large numbers
during the war era.
4.2. Metal and leather orthosis
One of the oldest materials that has ever been used was leather
(Banga et al., 2015). Leather is a material which was made from animal
skin that was treated chemically through a process known as tanning.
The tanning process will toughen the skin, increase its flexibility, and its
strength. The leathers that was used in the orthosis design will always
resemble a shoe, whereas the cuffs that hold the limbs in place were
designed like a cloth or straps with lace. A treated leather usually has
high tensile strength, tear resistant, and a good heat insulator. The
downsides of using leather are the chemical wastes after each tanning
process will cause pollution, and has low biodegradability. The ap-
proximate average value of the density of a leather is 860 kg/m3 (The
Engineering ToolBox., 2009).
In lower limb orthosis production, leather was usually paired up
with metal supports to withstand the force acting against the limbs. The
most common metals used in orthosis production are metal alloys,
steels, and any light metals with high tensile strength. The density of
metals could be as light as a Magnesium alloy which is 1700 kg/m3 52 or
as heavy as Tungsten alloy which is 20,000 kg/m3 52. The tensile
strength of metals are ranging from 11 MPa (Tin) (Ashby, 2016) up to
2200 MPa (Stainless Steel) (Ashby, 2016). Metal has high stiffness, thus
its modulus of elasticity will range around 13,000 MPa (Lead Alloys)
(Ashby, 2016) up to 380,000 MPa (Tungsten Alloys) (Ashby, 2016).
The advantages of using a metal-leather orthosis is that is usually
comes in a modular design. Thus, the shoe could be removed from the
metal fixtures or supports and exchange with a different shoe. The
downside of using this type of orthosis is that it is bulkier than any other
orthosis with low cosmetic value. In addition, the addition of both
metal and leather density within an orthosis causes this type of orthosis
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Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
becomes very heavy and need higher energy expenditure. Thus, making
the users put out an extra effort while walking with these AFOs on. In
addition, the thickness of the leather and metal causes these types of
materials to be unsuitable being worn in a highly humid area. The effect
towards the users would be excessive sweating and bad odour due to
the absorption of sweat into the leather.
In 1912, Edgar Stanley Weaver invented an invalid body support
that made use of both leather and metal (Weave, 1912). His invention
relates to body paralytic support device to enable users/patients to
regain regular body movement functions. Another inventor named
Douglas A. Slinger invented a foot list assist for foot drop in 1999 and
published his patent in 2002 (Slinger, 2002). The design helped a
person to walk better in an almost normal manner. A metal plate was
placed under the foot strap to enable the user walk on abrasive surfaces.
An elastic cord was connected to the foot strap towards the hip belt.
Both the foot strap and belt were made of leather. Another design
proposed by Sherk helped in reducing skin shear (Sherk, 2008). Sherk
created a metal AFO with floating T strap leather covered foam which
was attached to the shoe to ensure the reduction in skin shear upon skin
contact. The problem with these materials is that they are heavy and
bulky.
4.3. Plastics orthosis
Plastics are widely known as a semi-synthetic material. It can be
divided into two types which are thermoplastics and thermosets.
Thermoplastics are plastics which can be turned into a liquid when
heated and freezes into a glassy solid when cooled properly. This ma-
terial is convenient for orthosis fabrication due to the fact that it can be
moulded on a plaster model and made an orthosis quickly. Some ex-
ample of thermoplastics are Acrylic, Polypropylene (PP), Polyethylene
(PE), and Nylon. As for thermosets, these materials are usually in liquid
form before being cured and can be moulded into their final form after
being cured. Thermosets that has been moulded cannot be reshaped.
Epoxies, silicones, Polyurethanes, and Polyester resin are some of the
thermosets that are commonly used in orthotic devices.
Advantages of using plastics in orthotics application is that plastics
are poor conductors of heat and electricity, inflammable, and do not
corrode and rust. These properties will ensure that the fabricated or-
thosis would not harm the users regardless whether it is physically or
chemically. Its high mouldable aspects could also ensure that the or-
thosis can be mould into any shape or sizes which would perfectly fit
the users. Other than that, plastics are lightweight, durable, easy to
colour, and energy saving. Thus, orthosis made from plastics are the
lightest among other orthosis made from different materials while re-
taining its strength, and more aesthetically pleasing. The density of
plastics falls within the range of 36 kg/m3 up to 2200 kg/m3 52. As for
its tensile strength, it is around 0.24 MPa up to 170 MPa (Ashby, 2016).
The modulus of elasticity of plastics may vary widely depending on the
type of resins, reinforcing agents, and processing methods. It ranged
from 0.7 MPa up to 4100 MPa (Ashby, 2016). The negatives of using
F.S. Shahar, et al.
Table 1
Summary of current AFO materials’ advantages and disadvantages.
Materials Advantages
Wood - Renewable
- Good strength to weight ratio
- Does not rust
- Aesthetically pleasing
Metal and Leather - High tensile strength
- Tear resistant
- Good heat insulator
- Usually comes in a modular design
Plastics - Easily mouldable and reduces production time
- Poor heat and electricity conductor
- Inflammable
- Corrosive and rust resistant
- Lightweight and durable
- Good aesthetics value
- Low energy expenditure
Carbon Fiber Composite - Good strength to weight ratio
- Good aesthetics value
- Corrosive resistant
- Fatigue resistant
- Rust resistant
plastics is that it is indestructible which could potentially pollute the
environments. Even though, its wastes are melted to be removed, the
gas formed during the melting process are still very harmful for health
and helps in thinning the ozone layer. AFOs made by using plastics are
usually lighter than the rest of the materials available in the market.
However, it also causes skin irritation when it is used for a long period
of time.
Currently, with the existence of the additive manufacturing, plastic
has become the most sought-after material. Additive manufacturing
makes use of the 3D printing and 3D CAD model to produce an orthosis.
The orthosis will be printed out layer by layer the printer according to
the 3D model generated from CAD/CAM software. This could actually
reduce cost of production of the orthosis since it does not need to use a
plaster cast model as a reference as in the conventional method. The
possibility of redesigning and endless optimization also helps in pro-
ducing a better and functional orthosis while reducing the chance of
design failure.
Banga et al. created a 3D printed non-articulated AFO with four
different designs made from Polypropylene (PP) and Polyethylene (PE)
(Banga et al., 2018). Their method consists of 4 steps, start with de-
signing 3D CAD model, followed by FEA of the model, then results
retrieval, and finally modify any required parts. These steps were re-
peated until an optimum design has been achieved. They concluded
that the designs could reduce excessive heating and sweating during the
long-term usage. Kobayashi et al. also had used polypropylene in order
to design a custom articulated AFO comprised of the clevis style hinge
(Kobayashi et al., 2017). Their AFO's resistance to plantarflexion, dor-
siflexion and alignment can be adjusted independently. Another design
uses the hybrid between polypropylene and the canvas. The hybrid AFO
are lighter and enable faster walking speed (Do et al., 2014). A low-cost
production researched by Munguia and Dalgarno enables AFO design to
have better optimization by using 3D printing. The material they used
for the 3D printing was polyamide (Munguia and Dalgarno, 2013).
4.4. Carbon fiber reinforced polymer (CFRP) composite orthosis
A composite is a material that was made from two or more different
materials with distinct properties to complement each other and create
a completely different properties from its original materials. In ortho-
tics, most of the products were made from polymer composites.
Generally, polymer composites were manufactured from reinforcement
materials such as Aramid, Carbon fiber, and Glass fiber while its matrix
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Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
Disadvantages
- Variability of wood properties
- Produce harmful chemical wastes during production
- Low biodegradability
- Bulky and heavy
- Low cosmetic value
- High energy expenditure
- Cause excessive sweating and bad odour
- Indestructible which cause environmental pollution
- Production of harmful gasses during AFO production
- Causes skin irritation after long term of usage
- High production cost
- Not often eco-friendly
- Low reusability
- Design and manufacturing were too time consuming
- Not cost-effective for short term users
are from thermosets or thermoplastics resins.
Other than plastics, CFRP is one of the most widely known material
used to manufacture an AFO among all other polymer composites.
CFRP is a composite made from carbon fiber as its reinforcements, and
polymers as its matrix. This type of material is lightweight while still
retaining the strength of a metal (Mostafa et al., 2016). It is also much
more aesthetical when compared to other materials. The density of
CFRPs are ranging from 1500 kg/m3 until 1600 kg/m3 52. As for its
tensile strength, it ranges from 550 MPa until 1100 MPa (Ashby, 2016).
Finally, its modulus of elasticity could reach as high as 69,000 MPa
until 150,000 MPa (Ashby, 2016).
There are several advantages and disadvantages in using composites
for this application. Some of the advantages are the weight reduction
properties while still retaining its high strength. It also resists corrosions
and fatigue. Due to the way it was made, a composite mechanical
property can be tailored according to client's or application's require-
ment. Thus, making it useful for applications that needed two different
properties that opposes each other without sacrificing the either one of
them. The disadvantages of using composites are the cost of its pro-
duction, not often eco-friendly, and low reusability.
Zou et al. has proposed using CF sheets for their design (Zou et al.,
2014). It was found that when they did a comparison between CF AFO
and polypropylene AFO, the CF AFO performed better in the actual
mechanical testing. Bertram et al. stated that CF is highly suitable for
AFO due to its high stiffness and low density (Stier et al., 2015). They
also stated that the disadvantages of using fiber composites was that the
design and manufacturing were too time consuming. Furthermore, CF
composites are one of the most expensive material that is currently
available in the market (Mostafa et al., 2017). Thus, making it harder
for the users with low incomes to obtain one for themselves. Besides,
the users that only needs to wear the AFOs temporarily will definitely
think that CF AFO is not cost-effective. Table 1 summarises on the
advantages and disadvantages of current AFOs.
5. Reported work on the existing materials used in AFO
From the previous sub-sections, it can be seen that there were var-
ious designs and materials that has been used for manufacturing or-
thosis over the past several years. Among of all the materials, plastics
and CFRP has been used most. The ideal specification of an orthosis is
that it is lightweight, strong under tension and compression, stiff, and
durable (resist fracture under impact). Fig. 6, Fig. 7, and Fig. 8 shows
F.S. Shahar, et al.
Fig. 6. Comparison of densities between different materials.
the comparison of densities, tensile strength, and Young's Modulus
between several materials used in orthotic field respectively.
From Fig. 6, it shows that wood (160 kg/m3 - 1350 kg/m3) and
plastics (36 kg/m3 - 2200 kg/m3) are materials with the lowest den-
sities, followed by composites (1500 kg/m3 – 2000 kg/m3), and finally
metals (1700 kg/m3 - 20,000 kg/m3). In order to have a lightweight
orthosis, the density of materials used for its manufacturing must have a
low density. The weight of the orthosis will affect the energy ex-
penditure while walking. The lighter the weight of the orthosis, the
lower energy expenditure while walking. Thus, the user will not feel
fatigue as easily. This is especially important for users who needs high
energy level for sports such as wall climbing, hiking, cycling, and much
more. These sports need the users to be as light as possible for effi-
ciency, speed, and strength conservation.
In an ideal lightweight orthosis design, density are usually asso-
ciated with the strength of the materials used to manufacture the de-
vice. In an orthosis design, the most preferable material would be
materials with high strength to weight ratio. Therefore, from Fig. 7, it
can be seen that composites (140 MPa–1100 MPa) has the higher tensile
strength compared to wood and plastics (0.24 MPa–170 MPa), due to
the properties it retains or reinforced from one or more strong materials
such as carbon fiber, glass fiber, metal alloys and much more. However,
it has less strength when compared to metals (11 MPa–2200 MPa). By
comparing all of the materials in Fig. 7, wood has the least tensile
strength which ranged from 1.9 MPa up to 161 MPa. Unlike metal and
plastics which has uniform strength due to its isotropic (uniform inner
structure) nature, wood is well known as an anisotropic material where
its strength differ in different directions. Thus, with the correct wood
species, and wood orientation (along the grain/perpendicular to grain),
the strength of wood (oak – along the grain: 78 MPa) would be able to
surpass the strength of aluminium (70 MPa). By changing its
Fig. 7. Comparison of tensile strength between different types of materials.
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Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
orientation, wood (oak – perpendicular to grain: 7 MPa) could also
become weaker than an aluminium (70 MPa). Thus, considering the
ideal specification of an orthosis where it must be strong under tension
and compression while retaining its weight, the most suitable material
to be considered would fall into the composites and wood category.
An orthosis design must also have high stiffness which could resist
bending and shear stress. This particular mechanical property could
ensure that an orthosis could support the limb and keep the orthosis in
alignment without breaking. From Fig. 8, it can be seen that plastic
(0.7 MPa–4100 MPa) has the least stiffness, followed by wood
(5800 MPa - 12,000 MPa), composites (15,000 MPa–150,000 MPa), and
metal (13,000 MPa–380,000 MPa) respectively.
By comparing all three figures, it can be seen that composites satisfy
most of the specification needed for an orthosis which is lightweight,
high tensile strength, and high stiffness. These three properties will
always be correlated and could be explained through specific strength
and specific stiffness. Where,
MNm ⎞ Tensile Strength, σ (MPa)
Specific Strength ⎛⎜ ⎟ =
⎝ kg ⎠ Density, ρ 3
kg
m ( ) (2)
MNm ⎞ Young′s Modulus, E (MPa)
Specific Stiffness ⎛⎜ ⎟ =
⎝ kg ⎠ Density, ρ 3
kg
m ( ) (3)
These two equations will determine the strength/stiffness to weight
ratio which are widely used by engineers and researchers in aerospace
industry, medical care and sports to develop a product with the most
suitable stiffness/strength to weight ratio (Sultan et al., 2009). There-
fore, in order to obtain an optimum ratio for the development of an
orthosis, one of the variables such as the strength, stiffness or density
will be manipulated. From Equation (2) (Eqn. (2)), it can be seen that
F.S. Shahar, et al. Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185

Fig. 8. Comparison of stiffness of different types of materials.

Fig. 9. Comparison of specific strength of different types of materials.

Fig. 10. Comparison of specific stiffness of different types of materials.

high strength and low density will produce materials with high specific
strength. In other words, an orthosis which is lightweight with high
strength can be produced. Similarly in Equation (3) (Eqn. (3)), high
specific stiffness can be achieved by having low density and high
stiffness. Thus, fulfilling the ideal specification of orthosis having a
lightweight and high stiffness properties. Fig. 9 and Fig. 10 shows the
comparison of materials based on their specific strength and specific
stiffness.
By comparing each materials specific strength and specific stiffness
as shown in Figs. 9 and 10, it can be concluded that carbon fiber
composites has the most ideal specific strength and specific stiffness.
Thus, it has been widely utilised in manufacturing of an orthosis.
However, the downside of using this material is that it is more
expensive compared to other materials. Thus, for an orthosis that was
intended to be used temporarily, it is not cost-effective. In order to
reduce the cost, researchers used the next best material which satisfy
most of the specifications which is plastics. In addition, with the
emergence of 3D printing in the industrial field, manufacturing plastic
AFO using this technology could reduce the cost further and remove the
need to use a plaster model to shape the AFO.
It was found that there is small amount of research conducted using
carbon fiber composite AFO compared to AFOs which are manufactured
using plastics. Table 2 shows a compilation of research that has been
conducted over the past several years. From Table 2, it can be con-
cluded most of the research are using either polypropylene or carbon
fiber composite as AFO fabrication material. Currently, there are still no

179
 Table 2
Reported work on AFO.
Year Author Objective Body Material Fabrication Method Results Gap
part
F.S. Shahar, et al.

2019 Barrios-Muriel et al. 1 Define a procedure to obtain the skin Ankle- Nylon 12 PA 3D printing LoNEs could help predict the interaction 1 It uses plastic material
(Barrios-Muriel et al., strain field and LoNEs. Foot of devices to the skin, thus could help 2 Manufactured using 3D printing
2018) 2 Propose a design criterion for the reduce friction between the skin and technique
wearable devices device interface, reducing skin problems 3 Rigid design with no additional sensor
or actuator for joint movement
2019 Rodríguez Jiménez Design and build a fully mechanical knee Knee- 1 Housing of self-locking Thermoforming polymer Able to control knee joint movement 1 Device is bulky and heavy
et al. (Jiménez et al., orthosis Ankle- system – plastic sheets efficiently without buckling during 2 Device are made of combination of
2019) Foot 2 Gears – steel stance phase metal and plastic
3 Rods – Duraluminium 3 Joint movement controlled by PGT
4 Foot support – plastic
2019 Kobayashi et al. Investigate the effects of changing AFO Ankle- Polypropylene (PP) Thermoforming polymer Gait movement of the patients improved 1 Device was fabricated from PP
(Hunt et al., 2018) ankle alignment on lower limb joint Foot sheets and alignment of AFO could be used as 2 Joints movement are controlled by
kinematics and kinetics with constant one of the possible parameters for AFO Becker Triple Action ankle joints
dorsiflexion and plantarflexion resistance optimization
in individuals' post-stroke
2018 Wach et al. (Wach Characterize the compressive stiffness Ankle- 4 AFOs: 1 Thermoforming polymer Strut deflection and rotation may be 1 AFO material were fabricated from
et al., 2018) and device deflection of loaded AFO-limb Foot - 2 thermoplastic sheets used for predicting the performance and either plastic or carbon composite
complexes. AFO 2 Pre-preg carbon fiber functional outcome of an AFO 2 Rigid AFO with no additional hinge
- 2 carbon fiber composite sheet layup structure
2018 Takhakh & Abbas 1 Manufacture KAFO using carbon fiber Knee- Carbon fiber composite Pre-preg carbon fiber sheet The mechanical properties of carbon 1 AFO material was made from carbon
(Takhakh A and reinforced composite Ankle- layup fiber AFO are better than Polypropylene composite
Abbas S, 2018) 2 Compare the mechanical properties Foot 2 Manufactured using vacuum method
between traditional Polypropylene 3 Knee and ankle joints were controlled
metal – plastic and carbon composite by basic joints structure made from

180
AFO stainless steel
2018 Rodriguez et al. Propose a novel AFO design with negative Ankle- 1 Shafts, roller, CAM - stainless Pre-preg carbon fiber sheet Ankle joint movement and gait pattern 1 AFO is quite bulky
(Rodriguez et al., stiffness (nAFO) produced by a spring- Foot steel layup could be improved. 2 Material made from metal and carbon
2018) loaded 2 Casing - aluminium composite
CAM follower mechanism to compensate 3 Footplate, shank shell - 3 Joint was controlled by spring loaded
for the passive stiffness caused by the calf Carbon fiber composite CAM follower mechanism
muscle.
2018 Ulkir et al. (Ulkir Present the mechanical design and Ankle- Carbon fiber composite Pre-preg carbon fiber sheet The device were able to assist and 1 The AFO is lightweight but bulkier
et al., 2018) analysis of pneumatic AFO device Foot layup compensate the weakness and than a Polypropylene AFO
impairments of the ankle joint. 2 Material made from carbon composite
3 Joint movement assisted by PAM
2017 Totah et al. (Totah Proposed a multi-objective optimization Ankle- 1 Polypropylene (PP) None The proposed optimization method Only a simulated case study
et al., 2017) approach for choosing the appropriate Foot 2 Polyethylene (PE) could predict the optimal manufacturing
process, material and thickness that 3 Carbon composite choices to produce AFO.
minimizes production cost and time, and
maximizes device performance.
2017 Banga et al. (Banga Explore the possibilities of generating Ankle- 3 AFOs: 3D printing Reduce excessive heating and sweating 1 Material using plastic
et al., 2018) modular AFO elements, namely, calf, Foot 1 Polypropylene during long term usage 2 Rigid AFO with no joint movement
shank and footplate, with the localized 2 Polyethylene (Nylon) system implemented
composite reinforcement that aids in the 3 Polyamide 3 AFO fabricated either using FDM or SLS
optimization of the device in terms of
functionality, aesthetics, rigidity and cost.
2017 Silva et al. (Silva Produce metal/plastic hybrid components Arm 1 Device core – metal 3D printing The prototype could reduce excessive 1 The device is lightweight
et al., 2017) for orthopaedics applications by using 2 Device coating – plastic sweating, comfortable, waterproof, and 2 It was made of metal and plastic
additive manufacturing hygienic. 3 Manufactured using 3D printing
technology
(continued on next page)
Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
 Table 2 (continued)

Year Author Objective Body Material Fabrication Method Results Gap

part
F.S. Shahar, et al.

2017 Kobayashi et al. 1 Investigate the mechanical properties Ankle- Polypropylene Thermoforming polymer Articulated AFO appeared effective in 1 Material using plastic
(Kobayashi et al., of the novel articulated AFO that can Foot sheets influencing lower-limb joint kinematics 2 Joint movement was supported by
2017) independently adjust plantarflexion and kinetics of gait in the individual Triple Action ankle joint
resistance, dorsiflexion resistance and post-stroke.
alignment
2 Explore the effect of changing AFO
mechanical properties on ankle and
knee joint angle, moment and power
during gait in an individual post-
stroke.
2016 Amerinatanzi et al. Develop a new ankle foot orthosis that Ankle- 1 AFO shell – plastic (specific Thermoforming polymer Results of the motion analysis on a 1 Joint movement assisted by spring or
(Amerinatanzi et al., helps patients to have more normal ankle Foot plastic was not mentioned) sheets healthy subject during walking indicate hinge
2016) joint behaviour. 2 Hinge springs – NiTi alloy that the use of the super elastic NiTi
springs causes more normal walk
compare to the use of the conventional
stainless steel springs, especially during
swing
phase and heel strike.
2016 Gloger et al. (Gloger Development of lighter lower limbs Hip- 1 Mainframe and joint – Pre-preg carbon fiber sheet Gait cycle becomes smoother, energy 1 No sensory subsystem for joint
et al., 2016) orthosis which construction will decrease Knee- aluminium layup transfer from device to users was movement
battery consumption and increase users Ankle- 2 Fixtures or connectors - high improved
comfort during walking. Foot density PE and copolymer
3 Support at hip – Kydex
4 Joints and moving parts
-plastics

181
5 Foot and support - carbon
composite
2015 Stier et al. (Stier Present a 3D multi-scale structural Ankle- Carbon fiber composite Pre-preg carbon fiber sheet The proposed modelling strategy is in 1 Rigid AFO with no additional
et al., 2015) analysis methodology to speed up the Foot layup agreement with the experimental data components, sensors, or actuators for
design process of AFO showing that the numerical method can joints
be used to predict the structural
behaviour of a Carbon Fiber Reinforced
Orthosis
2015 Papi et al. (Papi Establish a method that would allow the Ankle- Polypropylene Thermoforming polymer The new method could be used to 1 AFO material was made from plastic
et al., 2015) quantification of the contribution of AFOs Foot sheets predict ankle moment contribution of
in the control of the ankle joint during the AFO and help in AFO optimization.
gait
2015 Rakib et al. (Rakib Develop a prefabricated Stance Control Knee- 1 Support/cuffs - Carbon fiber 1 Pre-preg carbon fiber Results revealed a better gait 1 Cuff of thigh and shank are adjustable
et al., 2015) Orthosis (SCO) with suitable material and Ankle- composite sheet layup for the cuffs 2 Device was prefabricated and made
design Foot 2 Footplate –Polypropylene 2 Thermoforming polymer from a combination of several
(PP) sheets for the footplate components made of carbon composite,
3 Basic structure/side bars aluminium support and joints, and PP
-Aluminium footplate
3 Knee and ankle joint movement
supported by stance-control-knee-joint
(SCKJ) and double-action-ankle-joint of
Becker Orthopaedics
2014 Zou et al. (Zou et al., Predict the mechanical behaviour of AFOs Ankle- 3 AFOs: 1 Pre-preg carbon fiber FEA model could predict the behaviour 1 2 AFO materials are using lamination
2014) using FEA models Foot 1 2 AFO made from Carbon sheet layup of AFO and has the potential in assisting of several Carbon fiber layers of
Fiber composite; 2 Thermoforming polymer in AFO optimization. different orientation to make a
2 1 AFO made from sheets composite
Polypropylene (PP) 2 The orthosis were rigid and
prefabricated
(continued on next page)
Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185
F.S. Shahar, et al. Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185

2 Material using PLA + CF reinforcement

using additive manufacturing technique
research being conducted on natural fiber composite as AFO fabrication

3 Ankle joint movement supported by a

1 Material using hybrid design of plastic

and leather + AliPlast foam for the T

3 Ankle joint supported by basic hinge

1 Material using metal frame support

materials. Furthermore, although there are some researches conducted
on fabricating AFO using 3D printing, the materials used are mostly
polypropylene. Thus, there are no research conducted on using natural
fiber composite in 3D printing.

simple hinge structure

2 Traditionally moulded

6. Natural composites as material replacement

1 Modular device
and canvas

From the previous section, it was discussed that composites have the

structure
highest compatibility with AFO as a fabrication material. An AFO de-

strap
sign needed to be lightweight, comfortable, strong, and have a good
Gap

aesthetic design. Table 3 shows the mechanical properties of AFO de-

veloped using the most common material used recently.
ankle dorsiflexion during heel strike

Low cost production with better

1 Survey shows hybrid AFO is lighter

compared to hybrid AFO (meaning

Reduce skin shear which could reduce

difference between the hybrid and

of the conventional AFO is higher

2 Gait analysis shows no significant

However, current composites such as carbon fiber, and glass fiber

design optimization compared to
conventional AFO except for the

movement during heel strike)

are much more expensive compared to metals, plastics, and wood. It

hybrid AFO has better gait
than conventional PP AFO

should also be noted that a composite is a material which was made

from one or more materials with different properties in order to create a
conventional method

new material with completely different properties. Thus, turning a low

cost raw material such as natural fiber into a composite is definitely
possible and has been proven since ancient civilization. From the past
several years, researchers have a renewed interest towards natural fiber
composite and had taken notice of their significance in material pro-
blisters
Results

duction. Its raw material does not only show that it is cheaper than
synthetic fiber (Salman et al., 2016a, 2017), natural composite is also
2 3D printing for footplate

lightweight, eco-friendly, and has an abundance supply due to its re-

1 Pre-preg carbon fiber
sheet layup for main
Thermoforming polymer

newability (Md Shah et al., 2019; Salman et al., 2016b, 2016c;

strut and footplate

Zakikhani et al., 2016).

Fabrication Method

Natural composites could be mainly found in plants. Namely a few

of such raw plant materials that could be used as natural composites are
and calf

Kenaf, jute, bamboo, pineapple leaf, and much more (Nor et al., 2019).
These fibers can provide flexibility in design and can be moulded into
sheets

None

any kind of shapes in order to fulfil a certain requirement or criteria of a

design. In addition, depending on the plant species, fiber orientation,
leather + AliPlast foam T straps
Polypropylene + canvas fabric

and matrix used, these natural composites could have high strength and
Polyamide + Carbon fiber

stiffness while maintaining its lightweight properties. These properties

were provided by the plant's cellulose structure. Cellulose is a natural
Metal AFO frame with

polymer which builds long fibrous cells that could be found within the
plant's stem (bast), leaves, or seeds. The natural composites made from
plants are mostly lightweight, biocompatible, recyclable, cheap, and
reinforced
Material

easily available. Natural composites could fulfil all of these require-

ments. Out of all natural composites, Kenaf fiber stood out the most due
to its abundance of supply in Malaysia, cheap raw material, and better
mechanical properties compared to other natural fiber.
Ankle-

Ankle-

Ankle-
Body

Kenaf also known as Hibiscus cannabinus is a type of fast growing

Foot

Foot

Foot
part

plant where the stalks could grow up to 5.5 m in height with a woody
base (Ayadi et al., 2017). Thus, when it is used in a composite, its fast
functionality, aesthetics, rigidity and cost
1 Investigate the effect of a hybrid AFO

Develop an AFO to correct Coronal-Plane

in patients with chronic hemi paretic

conventional plastic AFO in terms of

modular AFO elements: calf, shank, and

Explores the possibilities of generating

optimization of the device in terms of

growing characteristics ensures that there is no problem in its avail-

ability and production cost. Kenaf fiber can be found in the bast or core
footplate with localized composite

pathologies and reduce skin shear

2 Compare hybrid AFO with a

of the plant. Due to its absorption characteristics, Kenaf fiber has been
reinforcement that aids in the

used as a material to absorb oil and liquids. In addition, the Kenaf fiber's
convenience and effect

ability to absorb liquids will ensure that when it is used as a material for
an orthosis, the material will absorb the sweat produced in the enclosed
area of the orthosis. Thus, theoretically it could help in reducing the
possibility of skin irritation.
stroke
Objective

Table 4 shows the researches that had been conducted over the past
several years to enhance the mechanical properties of kenaf composite.
By comparing Tables 3 and 4, it can be concluded that, natural com-
posite could fulfil the minimum requirement of mechanical properties
Kyle A. Sherk (Sherk,
Munguia & Dalgarno

needed for a functioning AFO. Furthermore, by using kenaf composite,

Dalgarno, 2013)

the cost of raw material and weight of AFO can be reduce while still
(Munguia and
Table 2 (continued)

Do et al.58

maintaining the strength and stiffness of the materials. Table 5 shows

Author

the comparison of mechanical properties and cost of materials between

2008)

several synthetic fiber and natural fiber. By comparing Tables 3 and 5,

it can be seen that the strength of natural fiber are insufficient to
2013

2008
2014
Year

withstand the minimum strength exerted on the orthosis. Thus, this is

where composites play a significant role in enhancing the strength of

182
F.S. Shahar, et al. Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185

Table 3
Mechanical properties of AFO from several researches that uses Polypropylene (PP) or Carbon Fiber (CF) Composite.
Material PP PP PP CF CF

Thickness (mm) 5 6.1 6.4 3.6 –

Tensile Strength (MPa) 35.76 – 30 437 2735
Compressive Strength (MPa) – – – – 1309
Young's Modulus (GPa) 1.25 1.03 2.4 – 1.27
Poisson's Ratio – 0.43 0.43 0.50 0.20
Sources (Jweeg, Takhakh, Abbas) Chu and Reddy (1995) Zou et al. (2014) Zou et al. (2014) Krukonis et al. (2017)

Table 4
Enhanced mechanical properties of Kenaf Composite by several different methods.
Composite Enhancement method Tensile strength (MPa) Young's Modulus (GPa) Sources

Kenaf + Epoxy + NaOH Chemical treatment 53.33 3.89 Kumar et al. (2018)
Kenaf + Epoxy None 46.67 3.20 Kumar et al. (2018)
Kenaf + Kevlar + Epoxy Hybridising reinforcement 54.18 6.90 Muhamad Paudzi et al. (2018)
Kenaf + PP + NaOH Chemical treatment 44.00 1.80 Sosiati et al. (2019)
Kenaf + PP + PP-g-MA + MWCNT Hybridising reinforcement + Compatibilization 36.78 2.70 Yaghoobi and Fereidoon (2019)
Kenaf + PP + PP-g-MA Compatibilization 32.31 2.23 Yaghoobi and Fereidoon (2019)
Kenaf + Epoxy + MH Chemical treatment 39.36 4.76 Saba et al. (2019)

PP: Polypropylene.
NaOH: Sodium Hydroxide.
PP-g-MA: Polypropylene Graft Maleic Anhydride.
MWCNT: Multi-walled carbon nanotube.
MH: Magnesium Hydride.

the natural fiber, by combining a reinforcement material (fiber) and a
matrix (resin).
7. Conclusions and future prospective of this work
It can be concluded that there is a wide opportunity that can be
discovered by using kenaf composites as the AFO material. Basically,
this paper mainly reviews on the AFO material and possibility of re-
placing the current material used in the market. The overall conclusions
that can be derived from this paper is summarized as follows:
1) Orthosis has existed since ancient civilization which had gradually
developed from a simple splint towards more complex designs with
hinges, sensors, and form-fitting designs. Orthosis had been devel-
oped from wood, leather, metal, plastic, and finally carbon fiber
composite respectively throughout several eras. This paper mainly
discussed on Ankle-Foot Orthosis (AFO) which is an orthotic device
that supports the Ankle-Foot area for better gait movement. It is
commonly indicated use for foot drop treatment. There are mainly
three fabrication process used in manufacturing an AFO which are
thermoforming plastics, pre-preg carbon fiber composite, and 3D
printing.
2) Currently in the market and researches, the existing materials of
AFO are wood, metal and leather, plastics, and carbon fiber com-
posites. By comparing all these materials, it was found that carbon
composites are the most suitable material for AFO due to its low
weight, high strength, and high stiffness properties. However, its
raw material cost was too expensive which drives the researchers
and industries to use plastics more.
3) By comparing the mechanical strength of several AFOs made from
plastics and carbon fiber composite with the existing research on
Kenaf composite mechanical strength, it can be concluded that there
is a possibility of replacing plastics and carbon composites with
Kenaf composites. Kenaf composite does not only retains the low
weight, high strength and stiffness properties, it also reduced the
cost of raw materials, and recyclable.
4) Finally, it can be concluded that by the current trend of natural fiber
composite research around the world, an AFO which are cheaper,
stronger, eco-friendly, user-friendly, and lighter could be developed.
It can be expected more applications will use natural fiber composite
especially in the medical and rehabilitation field due to its low price,
biocompatibility and recyclability.
Some of the major findings from this review are:
1) An ideal AFO needs to be lightweight, stiff, and also strong in order
to support the lower limb while walking, standing, climbing, run-
ning and much more.
2) Material productions are highly dependent on the specific strength
and specific stiffness. However, these properties are highly affected
by strength/stiffness and density of the material. Thus, in order to
have a good ratio of specific strength/stiffness, the variables of
strength/stiffness and weight needs to be manipulated.
3) Most modern AFOs were made from plastics or carbon composites
due to its high specific strength and specific stiffness. However,
plastics has the tendency to pollute the environment after its use
whereas carbon composites were too expensive for a short term
usage.
4) Kenaf composite has the possibility to replace plastics and carbon
composite due to its cheap raw material compared to carbon com-
posite and similarity in specific strength and stiffness with plastics.
Currently, additive manufacturing has becoming well known due to
its flexible design and optimization, and also its long term cost-effec-
tiveness. Therefore, the future prospective work may implement the use
of natural fiber composite in additive manufacturing using 3D printing
techniques to reduce the current production time and cost.
Acknowledgement
This work is supported by UPM grant, GP-IPS 9647100. The authors
would like to express their gratitude and sincere appreciation to the
Department of Aerospace Engineering, Faculty of Engineering,
Universiti Putra Malaysia and Laboratory of Biocomposite Technology,
Institute of Tropical Forestry and Forest Products (INTROP), Universiti
Putra Malaysia for the close collaboration in this research.

183
F.S. Shahar, et al. Journal of the Mechanical Behavior of Biomedical Materials 99 (2019) 169–185

Appendix A. Supplementary data

(Jariwala and Jain,

2019; Ismail et al.,
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.jmbbm.2019.07.020.

1.30–1.50
0.39–0.80

10.0–55.0

3.34–3.76
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