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A Comparison of Gait With Solid, Dynamic, and No Ankle-Foot Orthoses in Children With Spastic Cerebral Palsy

Sandra A Radtka, Stephen R Skinner, Danielle M Dixon, M Elise Johanson


Children spastic CP
Abnormal joint motions
Dynamic equinus
Excessive ankle

Excessive knee flexion/hyperextension

plantar flexion

Hip flexion, adduction, and medial rotation
Anterior pelvic tilt

Pathological gait patterns

Temporaldistance characteristic

walking speed
Decreased stride length

Muscle timing

Abnormal timing of triceps surae group in equinus gait pattern Tibialis anterior muscle>>shortened activity during swing & prolonged activity into mid-stance Hamstring & quadriceps femoris muscle group >> present prolonged activity during stance

Equinus gait pattern LE orthoses
Solid AFO (polypropylene)

• • •

control ankle by using 3-force system reduce excessive ankle plantar flexion during stance cover posterior calf & mediolateral borders & sole of foot straps across the anterior upper tibia & front of the ankle


The rationale for design, purpose, and use of inhibitive AFO is purposed based on inhibitive & tone-reducing cast. (past 10 year)
No changes bony alignment of foot & ankle Change in stretch sensitivities of ankle plantar flexors

Improved stride length

Improved footfloor contact during gait

Casting (studies)

Improved passive ankle dorsiflexion

Increased ambulation ability

INTRODUCTION  Several authors recommend using inhibitive AFO >> more flexible >> lightweight >> easily worn with regular shoe than the cast   No research compare inhibitive cast & AFO on gait in children with spastic CP inhibitive AFOs compare with no AFO >> increased standing duration >> improve knee motion .

pelvis & trunk during standing & gait .INTRODUCTION  Dynamic AFO with a plantar-flexion stop Footplate Abnormal m. activity Biomachanical change .excessive ankle plantar flexion .motion of LE.

INTRODUCTION  Dynamic AFO with a plantar-flexion stop ◦ 2. more flexible.4 mm thick polypropylene ◦ enclosing the forefoot and ankle with anterior trim lines at the center of dorsum of foot & cover 1/3 of the posterior calf ◦ Toe loop stabilize the first digit ◦ Anterior forefoot strap ◦ Ankle strap  Thinner. & shorter than solid AFO .

Framework cast Solid AFO DAFO with plantarflexion stop DAFO DAFO with free plantarflexion LE orthoses Pathological gait Patterns of children with joint motions Temporaldistance characteristic spastic CP SMO Hinged Muscle timing AFO .

AIM of This Study To compare the effects of DAFOs with a plantar-flexion stop. and no AFOs on the gait of children with spastic CP Examined the effects of DAFO on improving joint motion and on producing more normal muscle timing during gait in children with spastic CP. . polypropylene solid AFOs.

polypropylene solid AFOs.Research Question Are there effects of DAFOs with a plantar-flexion stop. and no AFOs on the gait of children with spastic CP? .

and trunk. ◦ temporal-distance characteristics during ambulation with DAFOs. . solid AFOs. and no AFOs. pelvis.Hypotheses  There would be differences in ◦ the timing of lower-extremity muscle activity. ◦ joint motions in the lower extremity.

6 boys .4 spastic hemiplegia .Method-Subject 10 Children with spastic CP -Plantigrade foot in weight bearing during standing -Excessive ankle plantar flexion during stance phase of gait -Passive ankle dorsiflexion to 5o or more with knees extended -Passive hip extension of -10o or less (Thomas Test) .8 receive PT for gait training from once a months to twice a week – not control type of PT .5 wore hinged AFO > 1 yr .6 spastic diplegia .4 girls .Ashworth scale) .no orthopedic surgery during the past year & for duration of the study .passive hamstring muscle length of 60o or more (SLR Test) .2 not receive PT .no use of assistive devices .5 wore solid AFO > 1 yr .mild to moderate spasticity of LE(score1or 2 .

1 month No orthosis .1 month .initial 2-week period Solid AFOs .Method-procedure 10 Children with spastic CP No orthosis .2-week period DAFO with plantar flexion stop .

.Method-procedure   Gait measure -at the end of each of four intervention (1) surface electromyography (EMG) of the  gluteus maximus  hamstring  quadriceps femoris  triceps surae  tibialis anterior muscle groups to determine timing of these lower-extremity muscle groups during the stance phase Electrodes were applied longitudinal to the direction of the fibers of five muscle groups of the lower extremity with the greatest degree of excessive ankle plantar flexion during stance without orthoses. as determined by visual observation.

EMG muscle timing. of the five muscle groups was determined for each testing session. measure active periods for each muscle group for two trials (total of 10 gait cycles) normalized to the gait cycle as an average percentage of the stance phase.   . defined as the duration of muscle firing.

.] between two consecutive initial contacts on one foot) determined from footswitch signals by a computer software program  placed along the entire plantar surfaces of both feet and taped to the feet for tests without AFOs and to the shoes for tests with the orthoses.) ◦ stride length (distance [cm. including ◦ walking speed (distance over time [m/min.]) ◦ cadence(steps per min.Method-procedure  (2) contact-closing footswitches was used to obtain temporal-distance gait characteristics.

with a rest period allowed between trials to prevent fatigue.selected speed for at least two trials. Each subject ambulated on a 10-m walkway at a self. Collect data 1 trial when subject sitting or lying without moving & all muscle rest .Electromyographic & footswitch data >> record simultaneously with CODAS data-collection softwares.

◦ used to collect joint angle displacement ◦ Consisted of 6 cameras. hip. pelvis. ◦ Gait data were collected for 4 to 6 seconds over a 1.Method-procedure  (3) 3-D motion analysis system (Motion AnalysisTMII) to determine joint motions of the trunk. a video monitor. knee. and ankle at initial contact and mid-stance. and a computer. a video processor (VP-320).5-m length of the walkway .

coronal. and toe markers on the orthosis and shoe over anatomical landmarks for tests with orthoses. lower extremities. and transverse planes at a sampling rate of 60 frames per second . and pelvis. heel.  recorded images from the markers in the sagittal. bilaterally. for the tests without AFOs. Twenty-one retroreflective markers ◦ anatomical landmarks on the upper extremities. ◦ tape ankle.

Use the same limb as measure surface EMG in all 4 tests   . Joint motions were averaged for each testing session Use the greatest amount of excessive ankle plantar flexion in stance during ambulation without orthoses.

Reliability high ICC (footswitches) high ICC (EMG) high ICC (3-D motion analysis) except hip rotation at initial contact &mid-stance and hip adduction/abduction.Method. and trunk rotation at mid-stance .

pelvis.Data Analysis  Descriptive Statistic ◦ Temporal-distance gait characteristics ◦ LE. and trunk joint angles at initial contact & mid-stance ◦ Muscle timing for 5 LE muscle groups during stance phase for 4 interventions .

and interaction of diagnosis and intervention on temporal-distance gait bet. interventions with Tukey’s Honestly Significant Difference (HSD) p=.Data Analysis  Two-way analysis of Variance (ANOVA)repeated measure (adjusted alpha level) ◦ Test effects of diagnosis.  All sig. intervention. and muscle timing.05 . ANOVA tests ◦ Six post hoc pairwise. joint motions.

002). .Data Analysis  Clinical recommendations >> the most appropriate orthoses for each subject based on clinical assessment of temporal-distance gait characteristics and joint motions  Two-way analysis of Variance (ANOVA)repeated measure (adjusted alpha level) ◦ To examine the differences among subjects with the clinical recommendation of solid AFO. or either orthosis on temporal-distance gait characteristics (P < .02) and joint motions at initial contact and mid-stance (P<. DAFO.

 Power & effect size>>examine the probability of making a Type II error  For all nonsignificant dependent variables effect size<. power<.38.45  prone to a type II error need larger sample size to increase power of the test .

and stride length No differences at the P<. cadence.Results –  Temporal-Distance Gait Characteristics  No differences at the P<.02 level among the interventions of walking speed .02 level bet. The diagnoses of spastic diplegia & hemiplegia for walking speed.

(Table 2 & 4) .Results – Temporal-Distance Gait Characteristics  The mean stride length was increased and the mean cadence was decreased with both solid AFOs and DAFOs when compared with no orthoses.

 This study. increased stride length for both orthoses no difference in walking speed when compare DAFO. Some studies  Walking speed can be increased by a longer stride length or a faster cadence. solid AFO and no orthoses  increased stride length was not enough to produce a corresponding increase in walking speed.Discussion Temporal-Distance Gait Characteristics  Improved stride length with the DAFO compared with no orthoses  consistent with the results of the inhibitive cast studies. .

hip. and trunk at initial contact and midstance among the interventions. pelvis.002) No differences in joint motions of the knee.Results –  Joint Motions No differences between the diagnoses of spastic diplegia and hemiplegia for joint motions of the lower extremity. pelvis. and trunk at initial contact and mid-stance (Table7&8) (P<.(Table7)(P<.002)  .

Results – Joint Motions  Only the effects of the interventions for ankle motions at initial contact and mid-stance were significant.002) .(P<.

.Results – Joint Motions  The amount of ankle plantar flexion at initial contact and midstance in the interventions with no orthoses was reduced with both solid AFOs and DAFOs (Table 5 & 6).

. two orthoses ◦ No changes in proximal joint motions of the trunk. hip. pelvis. abnormal motions at the ankle and more proximal joints. and knee for both orthoses at initial contact & mid-stance  Not support the purposed effects of DAFO with plantar-flexion stop on the proximal joint motion during ambulation. ◦ No differences bet.  This study.Discussion Joint Motions Hylton proposed that DAFO's contoured footplate and total surface contact produces correct biomechanical alignment of the foot and ankle that improves distal stability and reduces compensatory.

which was a supramalleolar orthotic (SMO) design allowing plantarflexion.)  This study used 3-D motion analysis to measure motion more accurately than 2-D videographs use by Embrey et al. ◦ No changes in knee motions at initial contact & midstance with DAFO  Not consistent with the results of a single-subject design study by Embrey et al. (found improved knee motions in a child with CP who received physical therapy in conjunction with the use of a DAFO with free plantar flexion. .Discussion Joint Motions This study.

Children without pathology ◦ ◦ ◦ ◦ ◦ 0% 0% 0% 0% 9% to to to to to 43% 33% 51% 48% 79% (Sutherland D et al.Results –  Muscle Timing Muscle timing>> Duration of muscle firing starting from initial contact at 0%.the quadriceps femoris muscle for the lateral hamstring muscle for the gluteus maximlls muscle for the triceps surae muscle . 1988)  for the tibialis anterior muscle for. expressed as a percentage of the stance phase..

except triceps surae muscles (fired prematurely) (Table10)  No differences between the diagnoses of spastic diplegia and hemiplegia for timing of all muscle groups during stance phase.Results –  Muscle Timing This study. (P<.01)  No differences at among the interventions for timing of all muscle groups during the stance phase. (P<.01) . all muscles active in initial contact >>normal.

 .Discussion – Muscle Timing  Abnormal premature and prolonged activity of the triceps surae muscle group in a dynamic equinus gait pattern was not changed by either the solid AFO or the DAFO But the excessive ankle plantar-flexion motion during initial contact and mid-stance was reduced with both orthoses.

Discussions –  Factors affected the outcomes Test subject with barefoot for 2 interventions without orthoses but wore shoe when test with solid AFO & DAFO  Measurement error in placing reflective markers inconsistent on the subject reliability of joint angle measurement  Small sample size .

no change bet. no carryover effects from the first orthoses .Discussions –  Factors affected the outcomes Mild to moderate amount of excessive ankle plantar flexion during stance  Not use crossover design because of scheduling constraints (however. 2 interventions without orthoses)  Variability in the physical therapy for gait training with orthoses .

Results – Clinical Recommendations 2 subjects walking speed & stride length with DAFO 3 subjects same walking speed & stride length with both orthoses 2 subjects walking speed & stride length with solid AFO 1 subjects same walking speed & stride length with both orthoses 5 subjects recommend DAFO ( knee. hip. and pelvic motions) 3 subjects recommend solid AFO ( knee and hip joint motions) .

OO2). DAFO.Results – Clinical Recommendations No difference for joint motions. or either orthosis for temporal-distance gait characteristics (P<. and stride length with solid AFO & DAFO 2 subjects not recommend either DAFO or solid AFO  No differences among the subjects with the clinical recommendation of solid AFO.02) and joint motions at initial contact and mid-stance (P<. walking speed. (Table11) .

.Discussion  Parents. subjects. and their physical therapists ◦ Advantage>>DAFO was lighter and more cosmetically appealing ◦ Disadvantage>>slightly more difficult for the children to initially learn to independently take in and take off as compared with the solid AFO.

Discussion  When selecting the DAFO or solid AFO for children with spastic CP and equinus gait pattern need to be consider ◦ ◦ ◦ ◦ ◦ Orthotic cosmesis Durability Cost Ease of take in and take off the orthosis Effects on functional mobility such as sit-to-stand maneuvers or ambulation on uneven surfaces ◦ Individual differences in children (spastic diplegia/ hemiplegia –heterogenous group show variaton in gait) .

and ankle joint moments and powers during ambulation with solid AFOs & DAFOs .Further studies      Larger sample size Moderate to severe amounts of dynamic equinus during ambulation Receive similar physical therapy for gait training with orthoses Crossover design for assigning the orthosis worn initially Compare joint kinetics include hip. knee.

and other orthoses such as SMOs or hinged AFOs on other functional activities ◦ sitting to a standing ◦ Supine on floor to a standing ◦ Energy expenditure during ambulation. . DAFOs with a plantarflexion stop.Further studies   Compare effects of these 2 devices on gait in children with spastic CP Examine the effects of solid AFOs.


.trim lines anterior to both malleoli & straps across the front of ankle & anterior upper tibia Solid AFOs .5-5 cm below knee .4.8 mm thick .extend distally under toes& on mediolateral border of foot & proximally on posterior part of leg to 2.

4 mm thick  Enclosing the dorsum of the forefoot and ankle  Cover the posterior part of the leg to about 5 to 7.5 cm above the malleoli with straps across the ankle. forefoot. and first digit  DAFO with plantar flexion stop .2.

and normalize movements of the trunk. and LE in standing & during gait. Prevent excessive ankle plantar flexion. . To inhibit/ decrease abnormal reflexes in LE >> protecting the foot from tactile-induced reflexes. improve LE m.INTRODUCTION Casts    Decrease spasticity >> prolonged stretch & pressure on the tendon of triceps surae muscle & toe flexors. pelvis. timing.