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

SIVAPORN LIMPANINLACHAT 5436899 PTPT/D

INTRODUCTION
Children spastic CP
Abnormal joint motions
Dynamic equinus
Excessive ankle

Excessive knee flexion/hyperextension

plantar flexion
Decreased

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

INTRODUCTION
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

INTRODUCTION

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

INTRODUCTION

Dynamic AFO with a plantar-flexion stop

Footplate Abnormal m. activity Biomachanical change - excessive ankle plantar flexion - motion of LE, pelvis & trunk during standing & gait

INTRODUCTION

Dynamic AFO with a plantar-flexion stop

2.4 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, more flexible, & 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, polypropylene solid AFOs, 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.

Research Question

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

Hypotheses

There would be differences in

the timing of lower-extremity muscle activity; joint motions in the lower extremity, pelvis, and trunk; temporal-distance characteristics

during ambulation with DAFOs, solid AFOs, and no AFOs.

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) - passive hamstring muscle length of 60o or more (SLR Test) - mild to moderate spasticity of LE(score1or 2 - Ashworth scale) - no use of assistive devices - no orthopedic surgery during the past year & for duration of the study

- 4 girls - 6 boys - 4 spastic hemiplegia - 6 spastic diplegia - 5 wore solid AFO > 1 yr - 5 wore hinged AFO > 1 yr - 8 receive PT for gait training from once a months to twice a week not control type of PT - 2 not receive PT

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

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.

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. EMG muscle timing, defined as the duration of muscle firing, of the five muscle groups was determined for each testing session.

Method-procedure

(2) contact-closing footswitches was used to obtain temporal-distance gait characteristics, including
walking speed (distance over time [m/min.]) cadence(steps per min.) stride length (distance [cm.] 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.

Electromyographic & footswitch data >> record simultaneously

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

Method-procedure

(3) 3-D motion analysis system (Motion AnalysisTMII) to determine joint motions of the trunk, pelvis, hip, knee, and ankle at initial contact and mid-stance.
used to collect joint angle displacement Consisted of 6 cameras, a video monitor, a video processor

(VP-320), and a computer.

Gait data were collected for 4 to 6 seconds over a 1.5-m length of the walkway

Twenty-one retroreflective markers

anatomical landmarks on the upper extremities, lower extremities, and pelvis, bilaterally, for the tests without AFOs. tape ankle, heel, and toe markers on the orthosis and shoe over anatomical landmarks for tests with orthoses.

recorded images from the markers in the sagittal, coronal, and transverse planes at a sampling rate of 60 frames per second

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

Method- 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, and trunk rotation at mid-stance

Data Analysis

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

Data Analysis

Two-way analysis of Variance (ANOVA)repeated measure (adjusted alpha level)

Test effects of diagnosis, intervention, and interaction of diagnosis and intervention on temporal-distance gait characteristics, joint motions, and muscle timing.

All sig. ANOVA tests

Six post hoc pairwise- compare bet. interventions with Tukeys Honestly Significant Difference (HSD) p=.05

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, DAFO, or either orthosis on temporal-distance gait characteristics (P < .02) and joint motions at initial contact and mid-stance (P<.002).

Power & effect size>>examine the probability of making a Type II error

For all nonsignificant dependent variables effect size<.38, power<.45 prone to a type II error need larger sample size to increase power of the test

Results

Temporal-Distance Gait Characteristics

No differences at the P<.02 level bet. The diagnoses of spastic diplegia & hemiplegia for walking speed, cadence, and stride length No differences at the P<.02 level among the interventions of walking speed

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. (Table 2 & 4)

Discussion

Temporal-Distance Gait Characteristics

Improved stride length with the DAFO compared with no orthoses consistent with the results of the inhibitive cast studies. Some studies Walking speed can be increased by a longer stride length or a faster cadence.

This study; increased stride length for both orthoses no difference in walking speed when compare DAFO, solid AFO and no orthoses increased stride length was not enough to produce a corresponding increase in walking speed.

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<.002)
No differences in joint motions of the knee, hip, pelvis, and trunk at initial contact and midstance among the interventions.(Table7)(P<.002)

Results

Joint Motions

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

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).

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, abnormal motions at the ankle and more proximal joints.

This study,
No differences bet. two orthoses No changes in proximal joint motions of the trunk, pelvis, hip, 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.

Discussion

Joint Motions

This study,
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, 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.

Results

Muscle Timing

Muscle timing>> Duration of muscle firing starting from initial contact at 0%, expressed as a percentage of the stance phase. Children without pathology
0% 0% 0% 0% 9% to to to to to 43% 33% 51% 48% 79%
(Sutherland D et al., 1988)

for the tibialis anterior muscle for- the quadriceps femoris muscle for the lateral hamstring muscle for the gluteus maximlls muscle for the triceps surae muscle

Results

Muscle Timing

This study, all muscles active in initial contact

>>normal, 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. (P<.01)

No differences at among the interventions for timing of all muscle groups during the stance phase. (P<.01)

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

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, no carryover effects from the

first orthoses - no change bet. 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)

Results

Clinical Recommendations
No difference for joint motions, walking speed, 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, DAFO, or either orthosis for temporal-distance gait characteristics (P<.02) and joint motions at initial contact and mid-stance (P<.OO2). (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)

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 ankle joint moments and powers during ambulation with solid AFOs & DAFOs

Further studies

Compare effects of these 2 devices on gait in children with spastic CP Examine the effects of solid AFOs, DAFOs with a plantarflexion stop, 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.

THANK YOU

- 4.8 mm thick - extend distally under toes& on mediolateral border of foot & proximally on posterior part of leg to 2.5-5 cm below knee - trim lines anterior to both malleoli & straps across the front of ankle & anterior upper tibia

Solid AFOs

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

INTRODUCTION

Casts

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