RESEARCH REPORT PLATFORM PRESENTATION

DO ANKLE FOOT ORTHOSES IMPROVE BALANCE IN CHILDREN WITH SPASTIC DIPLEGIA? Jackson D^1,2, Mayston M², Alderson L^1,3, Brayley K¹, Main E^1,2,4; ¹Physiotherapy Department, Great Ormond Street Hospital, London, UK. ²Department of Physiology, University College, London. ³University of Hertfordshire. ⁴Institute of Child Health, University College London

PURPOSE: Ankle Foot Orthoses (AFOs) in children with spastic diplegia are thought to prevent deformity and improve functional balance by increasing the base of support, stabilizing the ankle joint and influencing the kinematics of more proximal joints. This study evaluated balance in children with spastic diplegia during walking and other activities in AFOs, shoes alone and barefoot using the GAITRite walkway and the Pediatric Balance Scale (PBS). RELEVANCE: There is considerable debate with respect to whether the use of AFOs remains appropriate following corrective orthopaedic surgery or once skeletal maturity is attained and deformities are unlikely to progress. Some physiotherapists believe AFOs remain useful for improving the child’s functional balance and it is important to provide evidence-based advice to families regarding their ongoing use. PARTICIPANTS: Ten children aged between 7-15 years with spastic diplegia were recruited. They were community ambulators and had been using AFOs for at least a year. None had undergone orthopaedic surgery or botulinum toxin injections in the preceding year, nor had any medical problems which may have influenced balance. METHODS: Each child was asked to walk four times along the GAITRite electronic walkway at their preferred speed in AFOs, shoes and barefoot. The order of these conditions was randomized to limit the effects of fatigue or increasing confidence. Normalized velocity, cadence, stride length and percentage of gait cycle in single leg support were selected as surrogate measures of stability. The child’s balance during other functional activities was then assessed with the PBS. The 14 items were scored on the 0-4 criterion based scale. Data for all conditions was collected on the same day by the same therapist. ANALYSIS: A two-way analysis of variance (ANOVA) was conducted to explore any differences in gait in AFOs, shoes or barefoot and post hoc comparisons were performed to test where these differences lay. Friedman’s test was used to test for differences in PBS scores between subjects in AFOs, shoes and barefoot. RESULTS: Mean normalized velocity, stride length and percentage of gait cycle in single leg support were significantly greater (p ≤ 0.02) when wearing AFOs compared with barefoot. Whilst there were also improvements in mean values for these parameters in shoes compared to barefoot, only the difference in stride length reached statistical significance (p ≤ 0.01). There were no significant differences in PBS scores in shoes or AFOs compared with barefoot. CONCLUSIONS: AFO’s improved balance in gait but had no significant effect on balance in other activities measured by the PBS in children with spastic diplegia. Whilst the shoes themselves had a positive impact on the child’s gait, the most significant effects were seen in the AFO footwear combination. IMPLICATIONS: Clinicians currently advising children to walk without their AFOs should reconsider the benefits they offer in gait as well as prevention of deformity. Therapists prescribing the AFOs should be aware that a large proportion of the improvements observed when wearing an AFO is from the footwear itself and so advise families on both the AFO and the footwear worn in conjunction with it. KEYWORDS: Cerebral Palsy, Orthotic Devices, Gait. FUNDING ACKNOWLEDGEMENTS: There was no external funding for this project. CONTACT: jacksd1@gosh.nhs.uk

ETHICS COMMITTEE: The Royal National Orthopaedic/Institute of Orthopaedics & Musculoskeletal Science Research Ethics committee