orthotics
The use of orthotics (devices that help support muscles, joints and bones), especially ankle-foot orthotics, in the management of ambulatory problems in cerebral palsy is common. They have been found to improve not only gait, but also the ability to stay standing and shift from sitting to a standing position. Specifically, orthotics are used to increase range of motion and stride length, reduce excessive flexor activity, and normalize foot-to-ground contact by correcting foot and/or ankle alignment in people affected with cerebral palsy.
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1. Impact of ankle-foot orthoses on static foot alignment in children with cerebral palsy
BACKGROUND: Children with cerebral palsy who are able to walk are often managed with an ankle-foot orthosis to assist with walking. Previous studies have shown kinematic, kinetic, and energetic benefits during gait with the addition of an ankle-foot orthosis, although the mechanism of this gait improvement is unknown. The ability of orthoses to correct foot malalignment in children with cerebral palsy is not known. The current study was performed to determine the impact of orthoses on static foot alignment in children with cerebral palsy. METHODS: A retrospective radiographic review was performed for 160 feet (102 patients). All patients had a diagnosis of cerebral palsy. Standing anteroposterior and lateral radiographs of the foot and ankle were made with the patient barefoot and while wearing the prescribed orthosis and were compared with use of the technique of quantitative segmental analysis of foot and ankle alignment. RESULTS: Analysis of the foot and ankle radiographs made with the patient barefoot and while wearing the brace revealed significant changes in all measurements of segmental alignment (p < 0.05). The magnitudes of these differences were small (<6 degrees or <10%) and would be considered clinically unimportant. The coupled malalignment of equinoplanovalgus (clinical flatfoot) showed radiographic correction of at least one segment (hindfoot, midfoot, or forefoot) to within the normal range in 24% to 44% of the feet. The coupled malalignment of equinocavovarus (clinical high arched foot) showed correction of at least one segment to within the normal range in 5% to 20% of feet. CONCLUSIONS: The present study demonstrates that the use of the ankle-foot orthoses failed to improve the static foot alignment in the majority of feet in children with cerebral palsy who were able to walk. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
[Westberry, D. E., Davids, J. R., Shaver, J. C., Tanner, S. L., Blackhurst, D. W. & Davis, R. B. (2007). Impact of ankle-foot orthoses on static foot alignment in children with cerebral palsy. The Journal of Bone and Joint Surgery. American Volume, 89(4), 806-13.]
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2. Rehabilitative orthotics evaluation in children with diplegic cerebral palsy: Kinematics and kinetics
Ankle foot orthoses (AFOs) are prescribed for ambulatory children with spastic diplegia to improve biomechanical alignment and functional capability. The purpose of this study was to employ quantitative motion analysis of the lower extremity to investigate two rehabilitative orthotics. The effects of hinged ankle foot orthoses (HAFO) and dynamic ankle foot orthoses (DAFO) for joint ankle management in children with cerebral palsy were compared. Sixteen (16) independently ambulatory children with a diagnosis of spastic diplegic cerebral palsy (7.5 +/- 2.9 yrs.) were included in the study. The biomechanical effects of two AFO designs were compared to barefoot using a 3-D motion analysis system. Significant differences between braced and unbraced conditions were found in peak ankle dorsiflexion, and peak ankle plantarflexion, knee stance peak flexion, knee swing peak flexion, hip stance peak flexion, and peak ankle plantarflexion moment (p < 0.01). Differences between the HAFO and DAFO were not seen in the kinematic and kinetic metrics. Further development of dynamic testing is suggested in order to advance our understanding of orthotic intervention. The value of quantitative description of gait dynamics is clearly indicated for rehabilitative application.
[Hassani, S., Roh, J., Ferdjallah, M., Reiners, K., Kuo, K., Smith, P. & Harris, G. (2004). Rehabilitative orthotics evaluation in children with diplegic cerebral palsy: Kinematics and kinetics. Conference Proceedings: Annual International Conference of the IEE.E Engineering in Medicine and Biology Society]
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3. Indications for orthoses to improve gait in children with cerebral palsy
Orthoses are frequently used to improve the gait of children with cerebral palsy. Optimal clinical decision-making for improving gait through orthotic management requires an understanding of the biomechanics of the foot and ankle during normal gait, the pathophysiology and pathomechanics of gait disruption in children with cerebral palsy, and the biomechanical characteristics of various orthoses. The clinician must seek to integrate his or her own goals with those of the child and family, the therapist, and the orthotist. Design, indications, and cost should be considered when choosing an orthosis. The physician can construct a paradigm for clinical decision-making, focusing on the evaluation of ankle/foot alignment, range of motion, and assessment of dynamic gait deviations. This paradigm will guide the clinician in the use of orthoses to improve gait in children with cerebral palsy. For optimal orthotic management, the physician must clearly identify the gait deviation and functional deficits to be addressed with the orthosis. The outcome of the orthotic intervention should be documented as objectively as possible.
[Davids, J. R., Rowan, F. & Davis, R. B. (2007). Indications for orthoses to improve gait in children with cerebral palsy. The Journal of the American Academy of Orthopaedic Surgeons, 15(3), 178-88.]
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4. Orthotic devices for ambulation in children with cerebral palsy and myelomeningocele
Children with cerebral palsy and children with myelomeningocele frequently require orthotic devices for standing and walking. The purpose of this article is to review the literature on orthotic devices for walking, present principles of lower-extremity orthoses, discuss designs of orthoses, and consider criteria for selecting orthotic devices. Although discussion of the devices is specific to children with myelomeningocele and to children with cerebral palsy, the orthoses can be used with children having other disabilities. The information presented should be of value to clinicians, educators, and researchers interested in reviewing orthotic applications for children with disabilities.
[Knutson, L. M. & Clark, D. E. (1991). Orthotic devices for ambulation in children with cerebral palsy and myelomeningocele. Physical Therapy, 71(12), 947-60.]
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5. A comparison of gait with solid, dynamic, and no ankle-foot orthoses in children with spastic cerebral palsy
BACKGROUND AND PURPOSE: This study compared the effects of dynamic ankle-foot orthoses (DAFOs) with a plantar-flexion stop, polypropylene solid ankle-foot orthoses (AFOs), and no AFOs on the gait of children with cerebral palsy (CP). These orthoses were used to reduce the excessive ankle plantar flexion during the stance phase of gait. SUBJECTS AND METHODS: Ten children with spastic CP (6 with diplegia and 4 with hemiplegia) were tested after wearing no AFOs for an initial 2-week period, solid AFOs for 1 month, no AFOs for an additional 2 weeks, and DAFOs for 1 month. The effects of the two orthoses and no AFOs on lower-extremity muscle timing, joint motions, and temporal-distance characteristics were compared. RESULTS: Both orthoses increased stride length, decreased cadence, and reduced excessive ankle plantar flexion when compared with no orthoses. No differences were found for the gait variables when comparing the two orthoses. CONCLUSION AND DISCUSSION: Based on the data, the authors believe that although both orthoses would be recommended for children with spastic CP and excessive ankle plantar flexion during stance, additional individual factors should be considered when selecting either orthosis.
[Radtka, S. A., Skinner, S. R., Dixon, D. M. & Johanson, M. E. (1997). A comparison of gait with solid, dynamic, and no ankle-foot orthoses in children with spastic cerebral palsy. Physical Therapy, 77(4), 395-409.]
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6. Biomechanical and electromyographic evaluation of ankle foot orthosis and dynamic ankle foot orthosis in spastic cerebral palsy
This study evaluated the biomechanical and electromyographic effects of conventional ankle foot orthoses (AFOs) and dynamic ankle foot orthoses (DAFOs) on gait in patients with spastic cerebral palsy (CP). Thirteen patients with dynamic equinus underwent motion analysis with electromyography. Both AFOs and DAFOs provided longer stride length, permitted pre-positioning for initial contact, and successfully controlled the excessive plantarflexion during the swing phase. Median frequency (MF) of EMG signal indicated that extremely high firing was found in the patient's lower limbs compared to controls that resulted in tiredness. The DAFOs allowed a significantly larger total ankle range of motion than the AFOs. However, AFOs significantly reduced the MF while DAFOs did not. The reduced MF seen when wearing AFOs suggested an improvement of walking endurance. The DAFO had the advantage of less restriction on ankle movement, which avoids muscular atrophy and improves orthotic compliance.
[Lam, W. K., Leong, J. C., Li, Y. H., Hu, Y. & Lu, W. W. (2005). Biomechanical and electromyographic evaluation of ankle foot orthosis and dynamic ankle foot orthosis in spastic cerebral palsy. Gait & Posture, 22(3), 189-97.]
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7. Orthotic management of gait in spastic diplegia
Orthoses are the primary conservative treatment option for control of dynamic equinus in spastic cerebral palsy. Our purpose was to compare the effects of a fixed ankle-foot orthosis (AFO), a supramalleolar orthosis (SMO), and a no-brace condition, but including shoes. Gait analyses were performed on 11 children with spastic diplegia, using a system with four cameras and two concealed force plates. Ensemble averages of time-distance, kinematic, and kinetic parameters were obtained for each condition, and a repeated measures analysis of variance was performed (P < 0.05). Among the important findings were as follows: (1) AFOs significantly reduced ankle excursion, increased dorsiflexion angle at foot strike, increased plantar flexion moment in push-off, decreased ankle power absorbed during loading response, and decreased ankle power generated in push-off; (2) SMOs did not restrict ankle range of motion or significantly alter the power and moment values at the ankle joint. Although neither brace changed stride length and walking speed, AFOs did offer some biomechanical benefits to the child with spastic diplegia, whereas SMOs appeared to have very little measurable effect.
[Carlson, W. E., Vaughan, C. L., Damiano, D. L. & Abel, M. F. (1997). Orthotic management of gait in spastic diplegia. American Journal of Physical Medicine and Rehabilitation, 76(3), 219-25.]
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8. Gait assessment of fixed ankle-foot orthoses in children with spastic diplegia
OBJECTIVE: To evaluate the effectiveness of ankle-foot orthoses (AFOs) in spastic diplegic cerebral palsy patients for whom orthoses were indicated to control equinus or pes planovalgus deformities. DESIGN: A retrospective, cross-sectional assessment was performed on diplegic subjects who had suitable barefoot and AFO gait trials on the same day. PATIENTS: Thirty-five subjects with a mean age of 8.7 yrs were included. Eighteen wore braces to control equinus and 17 to control pes planovalgus and crouch. OUTCOME MEASURES: Gait data assessed in all subjects included temporal-distance factors and sagittal kinematics. Force plate data to determine joint moments and powers were obtained in 20. Repeated measures analysis of variance was used to compare across conditions and indications. RESULTS: The cohort demonstrated increased velocity (10 cm/sec; p < .001), stride length (10 cm; p < .001), and percent single-limb support (1.8%; p < .002) using AFOs compared with barefoot gait. In braces, ankle excursion was reduced (p < .0001), while pelvic, hip, and knee excursions were increased to account for the temporal changes (p < .009). Effects were similar in both indication groups. In neither indication group did the AFO significantly alter knee position in stance. Kinetic analysis showed a reduction of abnormal power burst (p < .05) in early stance and an increase in late stance ankle moment (p < .05) with AFOs. Differences in gait characteristics and bracing effects are shown for both indication groups. CONCLUSION: Compared with barefoot gait, AFOs enhanced gait function in diplegic subjects. Benefits resulted from elimination of premature plantar flexion and improved progression of foot contact during stance. Effects on proximal joint alignment were not significant.
[Abel, M. F., Juhl, G. A., Vaughan, C. L. & Damiano, D. L. (1998). Gait assessment of fixed ankle-foot orthoses in children with spastic diplegia. Archives of Physical Medicine and Rehabilitation, 79(2), 126-33.]
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9. A comparison of gait with solid and hinged ankle-foot orthoses in children with spastic diplegic cerebral palsy
This study compared the effects of solid and hinged ankle-foot orthoses (AFOs) on the gait of children with spastic diplegic cerebral palsy (CP) who ambulate with excessive ankle plantar flexion during stance. Twelve children with spastic diplegic CP wore no AFOs for an initial 2-week period, solid AFOs for 1 month, no AFOs for 2 weeks, and hinged AFOs for 1 month. Lower extremity muscle timing, knee and ankle joint motions, moments and powers, and temporal-distance characteristics were measured during ambulation for an initial barefoot baseline test, and with solid and hinged AFOs for the other two tests. Both orthoses increased stride length, reduced abnormal ankle plantar flexion during initial contact, midstance and terminal stance (TST), and increased ankle plantar flexor moments closer to normal during TST. Hinged AFOs increased ankle dorsiflexion at TST and increased ankle power generation during preswing (PSW) as compared to solid AFOs, and increased ankle dorsiflexion at loading compared to no AFOs. No other significant differences were found for the gait variables when comparing these orthoses. Either AFO could be used to reduce the excessive ankle plantar flexion without affecting the knee position during stance. The hinged AFO would be recommended to produce more normal dorsiflexion during TST and increased ankle power generation during PSW in children with spastic diplegic CP.
[Radtka, S. A., Skinner, S. R. & Johanson, M. E. (2005). A comparison of gait with solid and hinged ankle-foot orthoses in children with spastic diplegic cerebral palsy. Gait & Posture, 21(3), 303-10.]
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10. A series of case studies on the effect of a midfoot control ankle foot orthosis in the prevention of unresolved pressure areas in children with cerebral palsy
This paper reports on a series of case studies where improvements were sought in muscle tone and gait in children with cerebral palsy. A Midfoot Control Ankle Foot Orthosis (AFO) was developed to control foot position in a cohort of patients with cerebral palsy (CP). The concept of controlling midfoot and hindfoot with an encapsulated internal Supra-Malleolar AFO that fitted into an external AFO was shown to be effective in ambulant children with CP. Some initial problems of compliance were noted and postulated to be due to difficulties associated with previous orthotic devices. Evidence from the case studies suggest that the developed Supra-Malleolar AFO orthoses enables children with CP to maintain mobility without skin tissue damage, delays the need for surgery and at the same time maintains the length of the Triceps Surae (Gastrocnemius and Soleus) complex. Plans for further research are discussed which will contribute to the evidence base for this particular orthotic device.
[Bill, M., McIntosh, R. & Myers, P. (2001). A series of case studies on the effect of a midfoot control ankle foot orthosis in the prevention of unresolved pressure areas in children with cerebral palsy. Prosthetics and Orthotics International , 25(3), 246-50.]
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11. The effect of hinged ankle-foot orthoses on sit-to-stand transfer in children with spastic cerebral palsy
OBJECTIVE: To investigate the effectiveness of the hinged ankle-foot orthosis (AFO) on sit-to-stand (STS) transfers in children with spastic cerebral palsy. DESIGN: Before-after trial. SETTING: University-affiliated hospital. PARTICIPANTS: Nineteen spastic diplegic children (age range, 2-6 y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The transitional movement of STS was tested in random order with children while wearing the barefoot and hinged AFOs. The temporal, kinematic, and kinetic data during the task were collected by using a motion analyzer (with 6 infrared cameras). Statistical comparison between barefoot and hinged AFO was done with the Wilcoxon signed-rank test. RESULTS: Total duration of STS transfer was significantly shortened with the hinged AFO (P <.05). The initial knee flexion, the initial angle, and the final angle of ankle dorsiflexion were increased with the AFO, compared with when barefoot (P <.05). However, the increased pelvic tilt and hip flexion while barefoot was not reduced with the AFO. The maximal moment and power of hip and knee joints were significantly increased with the AFO (P <.05), whereas the maximal moment and power of the ankle joint were not significantly changed when wearing the AFO. CONCLUSIONS: Although proximal compensatory strategy of increased pelvic tilt and hip flexion did not change with the hinged AFO, some improvements of temporal, kinematic, and kinetic parameters were identified during the task. These findings suggest that a hinged AFO is beneficial for STS transfer activity for children with spastic diplegia.
[Park, E. S., Park, C. I., Change, H. J., Choi, J. E. & Lee, D. S. (2004). The effect of hinged ankle-foot orthoses on sit-to-stand transfer in children with spastic cerebral palsy. Archives of Physical Medicine and Rehabilitation, 85(12), 2053-7.]
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