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A Comparison of Gait With
Solid, Dynamic, and NoAnkle-Foot Orthoses inChildren With Spastic
Cerebral PalsySandra A Radtka, Stephen R Skinner,
Danielle M Dixon, M Elise Johanson
SIVAPORN LIMPANINLACHAT 5436899 PTPT/D
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Decreased
stride length
Pathologicalgait
patterns
INTRODUCTIONChildren
spastic CP
Decreased
walking speed
Excessive knee
flexion/hyper-
extension
Hip flexion,
adduction, and
medial rotation
Anterior pelvic
tilt
Abnormaljoint
motions
Muscle
timing
Temporal-distance
characteristic
Dynamic equinusExcessive ankle
plantar flexion
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 duringstance
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Equinus gait patternINTRODUCTION
LE orthosesSolid AFO
(polypropylene)
control ankle by using 3-force system
reduce excessive ankle plantar flexionduring stance
cover posterior calf & mediolateral borders& sole of foot
straps across the anterior upper tibia &front of the ankle
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The rationale for design, purpose, and use ofinhibitive AFO is purposed based on inhibitive &tone-reducing cast. (past 10 year)
INTRODUCTION
Improved
stride length Change in stretchsensitivities of ankleplantar flexors
Increased
ambulation
abilityImprovedpassive ankle
dorsiflexion
No changes bony
alignment offoot & ankle
Casting
(studies)
Improved foot-
floor contact
during gait
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Several authors recommend using inhibitive AFO>> more flexible
>> lightweight
>> easily worn with regular shoe than the cast
No research compare inhibitive cast & AFO ongait in children with spastic CP
inhibitive AFOs compare with no AFO
>> increased standing duration
>> improve knee motion
INTRODUCTION
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Dynamic AFO witha plantar-flexion stop
INTRODUCTION
Footplate
Abnormal m. activity
Biomachanical change
- excessive ankleplantar flexion
- motion of LE,pelvis & trunkduring standing &gait
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Dynamic AFO with aplantar-flexion stop 2.4 mm thick polypropylene
enclosing the forefoot and ankle
with anterior trim lines at thecenter of dorsum of foot &cover 1/3 of the posterior calf
Toe loop stabilize the first digit
Anterior forefoot strap
Ankle strap
INTRODUCTION
Thinner, more flexible, &shorter than solid AFO
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Pathological
gait Patterns
of children with
spastic CP
Frameworkjoint
motions
Muscle
timing
Temporal-
distancecharacteristicLE
orthoses
castSolid AFO
DAFO
DAFOwith
plantar-flexion stop
DAFOwith freeplantar-
flexion SMOHinged
AFO
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To compare the effects of DAFOs witha plantar-flexion stop, polypropylene solidAFOs, and no AFOs on the gait of children
with spastic CP
Examined the effects of DAFO on
improving joint motion and on producingmore normal muscle timing during gait inchildren with spastic CP.
AIM of This Study
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Research Question
Are there effects of DAFOs
with a plantar-flexion stop,polypropylene solid AFOs, and no AFOson the gait of children with spastic CP?
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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, solidAFOs, and no AFOs.
Hypotheses
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Method-Subject10 Children with spastic CP
- 4 spastic hemiplegia
- 6 spastic diplegia
-Plantigrade foot in weightbearing during standing
-Excessive ankle plantar flexionduring stance phase of gait-Passive ankle dorsiflexion to 5oor more with knees extended
-Passive hip extension of -10o orless (Thomas Test)
- passive hamstring musclelength of 60o or more (SLR Test)
- mild to moderate spasticity ofLE(score1or 2 - Ashworth scale)
- no use of assistive devices- no orthopedic surgery duringthe past year & for duration of
the study
- 5 wore solid AFO > 1 yr- 5 wore hinged AFO > 1 yr- 8 receive PT for gaittraining from once amonths to twice a week not control type of PT
- 2 not receive PT
- 4 girls- 6 boys
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Method-procedure10 Children with spastic CP
No orthosis - initial 2-week periodSolid AFOs - 1 month
DAFO with plantar flexion stop - 1 month
No orthosis - 2-week period
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Gait measure -at the end of each of four intervention
Method-procedure (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 fibersof five muscle groups of the lower extremity with the greatest degree ofexcessive ankle plantar flexion during stance without orthoses, asdetermined by visual observation.
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measure active periods for each muscle group fortwo trials (total of 10 gait cycles)
normalized to the gait cycle as an averagepercentage of the stance phase.
EMG muscle timing, defined as the duration ofmuscle firing, of the five muscle groups wasdetermined for each testing session.
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(2) contact-closing footswitches was used toobtain temporal-distance gait characteristics,including walking speed (distance over time [m/min.])
cadence(steps per min.)
stride length (distance [cm.] between two consecutiveinitial contacts on one foot)
determined from footswitch signals by a computersoftware program
placed along the entire plantar surfaces of bothfeet and taped to the feet for tests without AFOsand to the shoes for tests with the orthoses.
Method-procedure
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Electromyographic & footswitch data >> record simultaneouslywith 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
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(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
Method-procedure
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Twenty-one retroreflective markers
anatomical landmarks on the upper extremities, lowerextremities, and pelvis, bilaterally, for the tests withoutAFOs.
tape ankle, heel, and toe markers on the orthosis andshoe over anatomical landmarks for tests with orthoses.
recorded images from the markers in the sagittal,coronal, and transverse planes at a sampling rateof 60 frames per second
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Joint motions were averaged for each testingsession
Use the greatest amount of excessive ankleplantar flexion in stance during ambulationwithout orthoses.
Use the same limb as measure surface EMG in all4 tests
h d li bili
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Method- Reliability
high ICC (EMG)
high ICC (footswitches)
high ICC (3-D motion analysis)except hip rotation at initial
contact &mid-stance and hipadduction/abduction, and trunk
rotation at mid-stance
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Data Analysis Descriptive Statistic
Temporal-distance gait characteristics
LE, pelvis, and trunk joint angles at initialcontact & mid-stance
Muscle timing for 5 LE muscle groups duringstance phase for 4 interventions
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Two-way analysis of Variance (ANOVA)-repeated measure (adjusted alpha level) Test effects of diagnosis, intervention, andinteraction of diagnosis and intervention on
temporal-distance gait characteristics, jointmotions, and muscle timing.
All sig. ANOVA tests Sixpost hocpairwise- compare bet.interventions with Tukeys Honestly SignificantDifference (HSD) p=.05
Data Analysis
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Clinical recommendations >> the mostappropriate orthoses for each subject based onclinical assessment of temporal-distance gaitcharacteristics 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, oreither orthosis on temporal-distance gaitcharacteristics (P < .02) and joint motions at initialcontact and mid-stance (P
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Power & effect size>>examine the probability ofmaking a Type II error
For all nonsignificant dependent variableseffect size
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No differences at the P
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The meanstride lengthwas increasedand the meancadence was
decreased withboth solid AFOsand DAFOswhen comparedwith noorthoses. (Table2 & 4)
Results Temporal-Distance GaitCharacteristics
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Discussion- Temporal-Distance GaitCharacteristics
Improved stride length with the DAFO comparedwith 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 whencompare DAFO, solid AFO and no orthoses increased stride length was not enough toproduce a corresponding increase in walkingspeed.
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No differences between the diagnoses of spasticdiplegia and hemiplegia for joint motions of thelower extremity, pelvis, and trunk at initialcontact and mid-stance (Table7&8) (P
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Results Joint Motions
Only the effects of the interventions for ankle motions atinitial contact and mid-stance were significant.(P
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Results Joint Motions The amount of
ankle plantarflexion at initial
contact and mid-stance in theinterventions withno orthoses wasreduced with bothsolid AFOs and
DAFOs (Table 5 &6).
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Discussion- Joint Motions
Hylton proposed that DAFO's contoured footplate and totalsurface contact produces correct biomechanical alignmentof the foot and ankle that improves distal stability andreduces compensatory, abnormal motions at the ankle andmore 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 withplantar-flexion stop on the proximal joint motion
during ambulation.
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Discussion- Joint Motions This study,
No changes in knee motions at initial contact & mid-stance with DAFO
Not consistent with the results of a single-subject
design study by Embrey et al. (found improved kneemotions in a child with CP who received physical therapy inconjunction with the use of a DAFO with free plantarflexion, which was a supramalleolar orthotic (SMO) designallowing plantarflexion.)
This study used 3-D motion analysis to measure motionmore accurately than 2-D videographs use by Embrey etal.
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Muscle timing>> Duration of muscle firingstarting from initial contact at 0%, expressed asa percentage of the stance phase.
Children without pathology (Sutherland D et al., 1988) 0% to 43% for the tibialis anterior muscle
0% to 33% for- the quadriceps femoris muscle
0% to 51% for the lateral hamstring muscle
0% to 48% for the gluteus maximlls muscle
9% to 79% for the triceps surae muscle
Results Muscle Timing
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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
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Abnormal premature and prolonged activity ofthe triceps surae muscle group in a dynamic
equinus gait pattern was not changed by eitherthe solid AFO or the DAFO
But the excessive ankle plantar-flexion motion
during initial contact and mid-stance wasreduced with both orthoses.
Discussion Muscle Timing
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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 theoutcomes
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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
Discussions Factors affected theoutcomes
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5 subjects
recommend
DAFO
( knee, hip, and pelvicmotions)
Results Clinical Recommendations2 subjects
walking speed & stridelength with DAFO
3 subjects
same walking speed &stride length with both
orthoses3 subjects
recommendsolid AFO
( knee and hip jointmotions)
2 subjects
walking speed & stridelength with solid AFO
1 subjects
same walking speed &stride length with both
orthoses
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No differences among the subjects with theclinical recommendation of solidAFO, DAFO, oreither orthosis for temporal-distance gaitcharacteristics (P
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Parents, subjects, and their physical therapists
Advantage>>DAFO was lighter andmore cosmetically
appealing
Disadvantage>>slightly more difficult for the children to
initially learn to independently take in and take off as
compared with the solidAFO.
Discussion
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When selecting the DAFO or solid AFO forchildren with spastic CP and equinus gait patternneed 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)
Discussion
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Larger sample size
Moderate to severe amounts of dynamic equinusduring 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 duringambulation with solid AFOs & DAFOs
Further studies
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Compare effects of these 2 devices on gait inchildren with spastic CP
Examine the effects of solid AFOs, DAFOs with aplantarflexion stop, and other orthoses such as
SMOs or hinged AFOs on other functionalactivities sitting to a standing
Supine on floor to a standing
Energy expenditure during ambulation.
Further studies
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THANK YOU
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Solid AFOs
- 4.8 mm thick
- extend distally under toes& on
mediolateral border of foot & proximallyon posterior part of leg to 2.5-5 cm belowknee
- trim lines anterior to both malleoli &straps across the front of ankle & anteriorupper tibia
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DAFO with plantar flexion stop
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 withstraps across the ankle, forefoot, and firstdigit
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INTRODUCTION
Casts Decrease spasticity >> prolonged stretch & pressure on the
tendon of triceps surae muscle & toe flexors.
To inhibit/ decrease abnormal reflexes in LE >> protectingthe foot from tactile-induced reflexes.
Prevent excessive ankle plantar flexion, improve LE m.timing, and normalize movements of the trunk, pelvis, andLE in standing & during gait.