Lower Limb Alignment, Assessment and Management by Orthoses in Children with Cerebral Palsy.

  • Clare MacFarlane

Student thesis: Doctoral Thesis


Cerebral Palsy (CP) is a neurodevelopmental condition well recognised to begin at
birth or early childhood and persisting through the lifespan. The condition has been defined as a group of permanent disorders impacting on the development of movement and postures in turn causing activity limitation. Impacts caused by CP are often accompanied by disturbances of sensation, perception, cognition, communication, and behaviour, by epilepsy and by secondary musculoskeletal problems.

Physiotherapists are allied health professionals who assist patients with optimising their health and wellbeing outcomes, such as musculoskeletal problems. These outcomes are achieved through evidenced-based care whereby physiotherapists assess, diagnose, and treat a wide range of health conditions throughout the lifespan. One discipline in physiotherapy pertains to the provision of care to the paediatric population, whereby the physiotherapist can assist in optimising a child’s mobility and strength (for example, in children with CP), thereby reducing or even preventing other sequalae associated with their
conditions (such as musculoskeletal discomfort and deformity). One treatment approach often take by physiotherapists is to prescribe lower limb orthoses, such as ankle-foot orthoses (AFOs). However, there is limited evidence on sensomotoric orthoses (SMotOs), which are used clinically in children with CP. As such, the research question underpinning this program of research was ‘Which lower limb orthoses are optimal for treating children with CP?’. Therefore, the aims of this program of research were to: investigate current lower limb assessment techniques, determine what lower limb orthoses were available for children with CP, determine the effects of these lower limb orthoses on the gait and gross motor skills of children with CP, and to determine if there are other, less commonly known, orthoses that improve gait and gross motor skills in children with CP. To answer the overriding research question and to achieve these aims, one narrative systematic review and six studies were undertaken.

CP is described in depth throughout Chapter 1, further exploring the role of
physiotherapy in paediatrics, specifically lower limb assessment and orthosis prescription. From assessment, physiotherapists are able to use their clinical reasoning and evidence-based research to prescribe therapy or aids (such as lower limb orthoses) to support their therapy management and achieve patient goals. Studies 1 and 2 described, and further investigated, current lower limb alignment assessment techniques, with particular focus on techniques to ascertain subtalar joint neutral and the use of this measure to prescribe
orthoses to treat tibial torsion.

Study 1 investigated the reliability of a lower limb alignment assessment technique. Fifteen adults and six children (n=21) were assessed in resting and neutral calcaneal stance position (RCSP and NCSP) through the Anterior Line Method by six allied health professionals. The allied health professionals were all familiar with the Anterior Line Method, with varying levels of experience from novice to expert. The results demonstrated that the RCSP appeared to be a more reliable measure than the NCSP across the ages. The findings of this study highlight that, the level of experience and familiarity of using the Anterior Line
Method may influence reliability, as will measuring adult subjects as compared to children.

Using the records of the experienced assessor, the effect of orthotics with gait plates on tibial torsion in children was investigated. Through Study 2 (located in Appendix C: Tibial Torsion in Children: A Retrospective Study), chart data were assessed to determine if changes in tibial torsion occurred due to time or effect of orthotics. There was a final yield of 33 files for review. Within the reviewed charts, there were 23 male participants and 10 female participants (initial age = 2.5 -14 years). The mean period of time between initial assessment of RCSP and malleolar position (MP) and final assessment was 42.97 (± 41.41; range 3 –
147) months. Significant changes in RCSP and MP were found. As time was not a significant factor in the changes of left or right RCSP or MP, changes were likely due to the intervention or other unknown factors. However, a significant determinant of the amount of change was the initial torsion score. The results demonstrated there are physical improvements in tibial torsion which may be of benefit to the typical child through a simple, non-invasive method of intervention.

Due to the first two studies informing lower limb alignment assessment and orthoses in typical children only, these measures were therefore not considered appropriate for use in children with CP. The second study was relocated to Appendix C: Tibial Torsion in Children: A Retrospective Study, to maintain the total thesis journey, but so as to not interrupt the flow of the thesis. As such, further investigation into appropriate assessments and lower limb orthoses for children with CP was required to inform future studies.

One primary focus of this thesis was lower limb orthoses, such AFOs and SMotOs, and their effect on functional movement in this specialised population. To inform this focus, a narrative systematic review (Chapter 3: Study 3) was conducted into lower limb orthoses and their effect on gait and gross motor skills (GMS) in children with CP. Seven studies, graded as of good to high quality (Kennelly’s grading system: 2011) informed the review. The volume of evidence presented in the literature supported the use of AFOs as a device to improve gait and GMS in children with CP. However, there were inconsistencies in the agreement of design and in their use. A potential benefit of a clearer defining of AFO prescription within research studies was noted. In addition, given its lack, further research on the effect of SMotOs on gait and GMS in children with CP was identified as potentially being of value with regard to future orthoses prescription. Following the narrative systematic review, Chapters 4 – 7 presented further studies that explored AFOs and SMotOs and their impact on gait, GMS and quality of life in children with CP.

From the literature, as reported in Chapter 3 and through further reading, there
appeared to be several clinically viable outcome measures to inform on changes in gait, GMS and quality of life in children with CP. These outcome measures were the Gross Motor Function Measure (GMFM-88), Berg Balance Scale (BBS), Timed Up-and-Go (TUG), Edinburgh Visual Gait Score (EVGS) and Cerebral Palsy Quality of Life (CPQoL) and it was these outcome measures that were selected as outcome measures to inform Study 4, a pilot feasibility study (located in Chapter 4).

The aim of the feasibility study was to determine the most effective and timely
outcome measures of gait, GMS and quality of life in children with CP. Five outcome measures (GMFM-88, BBS, TUG, EVGS, CPQoL) were applied to six children with CP. A pre-determined minimum participation rate of 50% was set as the requirement for the outcome measure to be considered for future studies. Three outcome measures (GMFM-88, BBS and EVGS) achieved 50% or more participation rate.

Using the three predetermined outcome measures identified in Study 4 (Chapter 4), Studies 5 and 6 (Chapters 5 and 6) further investigated the effect of AFOs and SMotOs on GMS and gait in children with CP. Study 5 used the GMFM-88 and the BBS to determine the effect of SMotOs and AFOs on GMS in children with CP. Nine children (n=9: mean age=5.4 ± 3.2 years: range 3–13 years), who wore both orthoses, were recruited via convenience sampling. Participants wore two different types of AFOs, being hinged-AFOs (n=4) and solid-AFOs (n=5). The GMFM-88 demonstrated medium positive change in three participants between orthoses. Sections D and E of the GMFM-88 demonstrated a 6% increase in score
(SMotOs over AFOs). On average, participants scored significantly (p=0.002) higher on the GMFM-88 when wearing SMotOs compared to AFOs. There was no significant difference between BBS total scores when wearing SMotOs and AFOs (p=0.928). Using the GMFM-88, an effective and significant benefit on GMS was seen when wearing SMotOs compared to wearing AFOs.

To inform on changes in gait, and as identified in Study 4 (Chapter 4), the EVGS was deemed to be a clinically relevant, timely and effective outcome measure of gait changes in children with CP. Therefore, the EVGS was used to inform on the effect of SMotO and AFO on gait in Study 6. Eleven participants were videoed walking 5m (any order) barefoot, in SMotOs, and in AFOs. Of the participants (mean age = 5.5 ± 2.9 years: range 3 – 13 years) two (n=2) were female and six (n=6) used assistive devices. Seven (n=7) could walk barefoot. Participants presented with spastic diplegia (n=4), spastic quadriplegia (n=6), and
spastic dystonic quadriplegia (n=1). Gross Motor Functional Classification System levels ranged I - IV. Total EVGS for SMotOs (7.62) and AFOs (14.18) demonstrated improved gait when wearing SMotOs with no significant differences between barefoot and AFOs. The results suggested SMotOs may be a viable option to improve gait in this population.

Along with the effect on gait and gross motor skills, a further interest was taken in how the orthoses affected the quality of life in children with CP. As the CPQoL did not meet the minimum participation rate (as per Study 4: Chapter 4), a specific quality of life questionnaire was created with the aim to identify key themes in relation to AFO and SMotO. A self-administered 24-item questionnaire was designed and consisted of two sections: section one related to AFOs and section two related to SMotOs. Study 7 (Chapter 7) employed a qualitative phenomenological approach to determine the effect of SMotO and AFO on quality of life. Participants were recruited via convenience sampling. Sixteen (69.57%) local and interstate families consented and returned the questionnaire. Of these, 81.3% were prescribed solid-AFOs, 18.8% were prescribed hinged-AFOs and one child was prescribed a dynamic-AFO (supramalleolar). There were four key themes identified: 1) time, 2) reason, 3) function, and 4) comfort and dislike. Half of the participants (50%) reported
wearing both orthoses, 43.8% did not wear AFOs anymore and one wore AFOs only. The most common reason for AFO prescription was ‘alignment’ (43.8%). Six families (37.5%) were told the reason for AFOs being prescribed to their child was ‘because the child has CP.’ There were numerous functional improvements seen in both AFOs and SMotOs, such as walking and balance. When asked if their child was comfortable wearing their AFOs, 43.8% reported a mix of comfortable and uncomfortable, and fifteen families (93.8%) disliked the restriction in movement from the AFOs. Ten families (62.5%) disliked the way the AFOs
fit into shoes, and nine families (56.3%) disliked the bulkiness of the AFOs. With regard to SMotO, five families (31.3%) disliked the way they fit into shoes and seven families (43.8%) reported their child experienced pressure areas. Overall, the results trended towards a preference of wearing SMotOs for comfort, function, and in general, as preference to AFOs.

Having investigated both quantitative and qualitative data from the participants, to further create depth to the body of research presented, a case series was conducted with the specific focus to provide snapshots of the individual children with CP. Chapter 8 presented a case study series aimed to enrich the volume of work presented in this thesis, and to provide a clinically relevant picture to physiotherapists working with children with CP. .

Overall, this program of research demonstrated the Anterior Line Method and gait plate orthoses may not be viable for children with CP and established that there is a significant positive effect on gait, gross motor skills, and quality of life in children with CP when they wear SMotOs when compared to AFOs. Clinically, SMotOs provide an alternate option for AFOs in children with CP and as such, with further research, could become a wider used orthoses in this population. Future research should include investigations into creating clinically applicable lower limb alignment assessment techniques, modifications to current AFOs and further expand evidence supporting the use of SMotO to improve gait, GMS and quality of life in children with CP.
Date of Award13 Oct 2021
Original languageEnglish
SupervisorWayne Hing (Supervisor) & Rob Orr (Supervisor)

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