Gait
A literature review (Autti-Ramo et al, 2006) summarized the effectiveness of using upper and lower limb casting/orthoses in children with cerebral palsy from 5 systematic reviews. It was found that Orthoses that restrict ankle plantar flexion have a favorable effect on an equinus walk, but the long-term clinical significance is not yet certain.
A cross-sectional study (Balaban et al, 2007) assessed the effectiveness of a hinged ankle-foot orthosis on gait impairments and energy expenditure in children with hemiplegia. It was demonstrated that AFOs improved walking speed, stride length and single support time (p<0.01). Double support time was decreased significantly (p<0.02) with AFOs, and no change in cadence (p >0.05). Ankle dorsiflexion at initial contact, midstance and midswing showed significiant increase (p<0.01). Knee flexion at initial contact was decreased (p<0.02) but no significant change in maximum knee extension at stance and maximum knee flexion at swing was obtained (p>0.05). The oxygen consumption was significantly reduced during AFO walking (p<0.05).
A quasi-experimental study (Bahramizadeh et al, 2011) investigated the influence of floor reaction ankle foot orthosis on postural flexion (crouch position). It was found that the maximum knee extension was statistically significant in children with cerebral palsy when barefoot compared to wearing braced footwear (p < 0.05, t = 10.01). Anterior-posterior and medial-lateral displacement, anterior-posterior velocity and anterior-posterior phase plate portrait of center of pressure were not statistically significant between children with CP with/without a floor reaction ankle foot orthosis (p < 0.05).
A cross-sectional study (Bennett et al, 2012) examined the effects of ankle foot orthoses on the energy recovery and the mechanical work performed by children with cerebral palsy during walking. Outcomes were assessed with and without the subjects’ AFOs. There was an increase in stride length (p<0.005), energy recovery, and potential energy and the kinetic energy variation with the use of AFOs. However, there was no change in the mechanical work performed to walk or the normalized center of mass vertical excursion.
A quasi-experimental study (Brehm et al, 2008) investigated the effects of ankle-foot orthoses on walking efficiency and gait in children with cerebral palsy. It was found that speed was 9% faster (p<0.001) and energy cost was 6% lower (p=0.007) when walking with an ankle-foot orthosis. However, the Gillette Gait index stayed the same (p=0.607).
A systematic review (Figueriredo et al, 2008) evaluated the quality of current research on how ankle-foot orthoses influence gait in children with cerebral palsy. The literature suggests positive effect of AFOs but studies using high quality methods are still lacking. Standard terminology to define AFOs was noted.
A consensus statement (Morris et al, 2011) demonstrating that substantial evidence suggests that AFOs that control the foot and ankle in stance and swing phases can improve gait efficiency in children (GMFCS Levels I-III). Little high quality evidence exists to support the use of orthoses for the hip, spine or upper limb. A minimum of six hours of stretching per day is proposed to be beneficial in maintaining length of the soleus muscle, and solid AFOs for prolonged periods may do this, potentially reducing the need for Achilles tendon surgery.
Conclusion: There is limited evidence (level 2b) from several quasi-experimental studies demonstrating the positive effects of lower limb bracing on gait in children with cerebral palsy.
Muscular control
A high quality RCT (Olamaa et al, 2013) evaluated the effect of the three-sided support ankle–foot orthosis on standing balance of children with spastic diplegic cerebral palsy. Comparison between post-treatment mean values of all stability indices showed significant improvement in favor of the study group (p<0.05). This study demonstrates that the three-sided support AFO in conjunction with a physical exercise program is beneficial in the rehabilitation of spastic diplegic cerebral palsy as it enables children to gain more balance control and postural reactions.
A high quality RCT (Elliott et al, 2011) investigated changes in upper limb fluency of movement in children with cerebral palsy following Lycra splint wear, and explored the efficacy of Lycra splints for those with spastic and dystonic hypertonia. Significant difference between baseline and three months of Lycra splint wear in the movement substructures; movement time, percentage of time and distance in primary movement, jerk index, normalized jerk and percentage of jerk in primary and secondary movements. Changes were greatest in children with dystonic hypertonia.
A pre-post study (Ghalwash et al, 2013) examined whether adhesive taping is effective in controlling genu recurvatum in children with diplegic cerebral palsy. No significant differences were found between groups over time (P = 0.805).
A quasi-experimental study (Rha et al, 2010) identified the characteristics of static standing balance and its postural control mechanisms during quiet side-by-side standing while wearing hinged AFOs in children with bilateral spastic cerebral palsy. It was found that hinged AFOs for children with cerebral palsy may be helpful in improving the postural control mechanisms but not the postural stability in quiet side-by-side standing.
A case-control study (Degelean et al, 2012) analyzed the effect of ankle-foot orthoses on trunk postural control and lower limb intersegmental coordination in children with mild spastic diplegia (GMFCS I or II). Significantly greater trunk excursions were found in children with cerebral palsy when walking with and without AFOs as compared to controls. When wearing AFOs, children with cerebral palsy showed increased trunk frontal angular velocity. Typically developing children wearing orthoses showed increased trunk frontal displacement. Wearing orthoses induced significant changes in shank and foot elevation in both groups. This study demonstrates that ankle-foot orthoses improve lower limb coordination but increase trunk motion when walking in children with cerebral palsy.
A pre-post study (Vekerdy et al, 2007) investigated the effects of a thoracic-lumbar-sacral orthosis with non-rigid SIDO frame in non-ambulant children with cerebral palsy. The study demonstrated positive effects on sitting posture.
Conclusion: There is moderate evidence (level 1b) from one high quality RCT demonstrating the positive effects of lower extremity bracing on muscular control in children with cerebral palsy. There is moderate evidence (level 1b) from one high quality RCT demonstrating the positive effects of orthotics on upper extremity muscular control in children with cerebral palsy.
Range of motion
A literature review (Autti-Ramo et al, 2006) summarized the effectiveness of using upper and lower limb casting/orthoses in children with cerebral palsy from five systematic reviews. It was found that casting of the lower limbs has a short-term effect on PROM. It was also found that the evidence on managing upper limb problems with casting or splinting in children with cerebral palsy is inconclusive.
Conclusion: There is limited (level 2b) evidence from one literature review of the positive effects of bracing/lower limb casting on the range of motion in children with cerebral palsy. There is inconclusive evidence (level 2b) from this same literature review regarding the effects of upper limb casting/splinting in children with cerebral palsy on range of motion.
