SELECTED TOPIC: CEREBRAL PALSY

Orthotic Management of Children with Cerebral Palsy

Christopher Morris, MSc, SR Orth

he International Classification of Functioning, Disability and Health (ICF) distinguishes impairments of

body structure from activity limitations and participation exclusions.1 By definition, the impairment known as
cerebral palsy (CP) describes damage to the immature brain
resulting in problems with balance, coordination, and movement. Understanding the effects of such a complex condition
is a constant challenge to developing treatment regimens to
improve the health of children with CP. A consensus for
describing the primary neurological impairment has been
presented by the group for the Surveillance of Cerebral Palsy
in Europe (SCPE).2 The impact of skeletal growth during
childhood can compound the primary problem if muscles fail
to lengthen in proportion to their adjacent long bones.
Therefore, although CP is by definition a static neurological
lesion, the phenotype has also been labeled with the secondary impairment of a progressive neuromuscular deformity.3
Children with CP are often limited in their activities because of primary and secondary impairments. A valid and
reliable means of measuring functional limitations in children with CP is now possible using the Gross Motor Function
Classification System (GMFCS) for children up to 12 years
old.4 The GMFCS enables clinicians to describe the severity of
a childs functional limitations in one of five levels. Children
in Level I are only mildly affected and can achieve most the
activities of their age-matched healthy counterparts, with
only modest qualitative differences. Conversely, children in
Level V are the most limited in their activities and have little
ability to control their head and trunk posture to counter the
effects of the motor impairment and gravity. Rates of functional limitation in mobility, manual dexterity, speech, and
vision, and to a lesser extent hearing and cognition, have
been shown to correlate with GMFCS level.5

body structure or to assist function, although for children

with CP, orthoses are frequently designed to achieve both of
these aims. The aims of lower limb orthotic management of
CP were identified by the consensus conference convened by
the International Society of Prosthetics and Orthotics6:
To correct and/or prevent deformity
To provide a base of support
To facilitate training in skills
To improve the efficiency of gait
It is clear that the first of these aims fits with interventions
designed to affect the body structure, whereas the remainder
involve overcoming activity limitations. These aims may similarly be applied to the role that orthotic interventions can
play in the management of postural impairments of the trunk
and upper limbs. However, some degree of compromise is
necessary because orthoses prescribed to prevent or correct
deformities can impose additional activity limitations by restricting movement.

To Correct and/or Prevent Deformity

Mobile joint deformities caused by gravity or unbalanced
muscle forces can be corrected passively and the position
maintained using orthoses. Fixed deformities caused by relative shortening of muscles and soft tissues and structural
deformities of abnormal bone shape cannot be passively corrected and must be accommodated in orthoses. Ensuring that
muscles spend more than 6 hours during each 24-hour period in an elongated position may help to prevent or reduce
the rate of progressive contractures.7 However, stretching
muscles using active forces for shorter periods may perhaps
be more effective than maintaining a static position to increase muscle length and hence the available range of motion
at joints.8

To Provide a Base of Support

TREATMENT GOALS
In conjunction with other medical, surgical, and therapeutic
interventions, orthoses continue to play an important role in
the physical management of children with CP. Orthoses are
designed with one of two primary aims: either to affect the
CHRISTOPHER MORRIS, MSc, SR Orth, is a Principal Orthotist at
the Nuffield Orthapaedic Centre NHS Trust; and a Graduate Student
with the Nuffield Department of Clinical Medicine, University of
Oxford, affiliated with the National Perinatal Epidemiology Unit,
Oxford, UK.
Copyright 2002 American Academy of Orthotists and Prosthetists.
Correspondence to: Christopher Morris, MSc, SR Orth, Department
of Orthotics, Nuffield Orthopaedic Centre, NHS Trust, University of
Oxford, Oxford OX3 7LD, U.K.; E-mail: christopher.morris@
perinat.ox.ac.uk
150

Stability in any position of lying, sitting, or standing requires

consideration of both intrinsic and extrinsic factors. Intrinsic
stability involves controlling the position of the center of
mass within the body. Extrinsic stability involves maintaining
the center of mass within the supporting area. Hip abduction
orthoses may improve stability and sitting balance by increasing the size of the support area, either in combination with a
spinal orthosis or by encouraging independent control for the
position of the center of mass of the trunk. Similarly, standing frames use hip-knee-ankle-foot-orthoses to control body
position and wide bases of support to provide upright postural
stability.

To Facilitate Training in Skills

Normal functional development can be impeded by impairments of coordination and movement. Orthoses can maintain
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optimum biomechanical alignment of body segments encased

within the orthosis. These effects may enable children to
overcome activity limitations by focusing training on unrestricted parts of their bodies over which they have better
control. Common training targets include encouraging head
control by providing trunk stability or using wrist orthoses to
facilitate manual dexterity when grasping objects. For lower
limb orthoses, the effects also include influencing external
movements acting around proximal joints by altering the line
of action of the ground reaction force during standing and
walking.9 There may be some motor learning effect when
children repeat movements through the altered sensations
provided by the orthosis.10

TO IMPROVE THE EFFICIENCY OF GAIT

Children who are able to achieve upright locomotion must be
encouraged to optimize their ability to achieve an efficient
gait. Gage11 has described the prerequisites of normal gait:
1. Stability of the supporting leg during stance phase:
requiring an appropriate foot-floor contact area, minimizing the external moments acting on the knee, and
creating adequate hip abduction power to prevent the
pelvis dropping on the unsupported side.
2. Clearance of the foot from the ground during swing
phase: requiring adequate hip and knee flexion and
ankle dorsiflexion of the swinging limb.
3. Appropriate prepositioning of the limb at the end of
swing phase: created by knee extension and ankle dorsiflexion.
4. Achieving an adequate step length: by hip extension of
the stance limb and unrestricted advancement of the
swinging limb.
5. Conservation of energy expenditure through reduced
excursion of the center of mass of the body.
Lower limb orthoses may improve gait efficiency by restoring these prerequisites through the manipulation of
forces acting on the body. Orthoses may reduce energy expenditure further by decreasing the need for compensatory
gait deviations to achieve locomotion.

ASSESSMENT
A thorough assessment of the childs needs is essential. The
needs of each child will be influenced by the severity of their
impairment and their individual activity limitations. The consensus conference document considered orthotic intervention as relating to three levels of function (i) the prestanding
child (recognizing that this may be the highest level of
activity for some children), (ii) the standing child, and (iii)
the walking child.6
Collating the information required to define the treatment
goals and therefore decide whether an orthosis will form a
useful part of an overall physical management plan is a
multidisciplinary task. The information required will usually
include a precise diagnosis using the SCPE classification;
functional gross motor status using the GMFCS; measureVolume 14 Number 4 2002

Orthotic Management of Children with Cerebral Palsy

ment of ranges of joint motion both passively and actively;

selective muscle control, strength, and spasticity; and joint
congruency and integrity judged by radiological investigation. In addition, an assessment of sitting and standing balance and gait analysis will be required for children with those
abilities. Other factors influencing the development of a realistic plan for physical management include considering the
environments in which the child interacts, behavioral characteristics, and any relevant associated conditions, such as
epilepsy, gastroesophageal reflux, or the need for gastrostomy
feeding tube access.
Once the treatment goals are defined, many therapeutic
interventions other than orthoses are available, such as oral,
intramuscular, or intrathecally administered medications, orthopaedic and neurological surgery, physical and occupational therapy, wheelchairs, walking aids and other assistive
technology, and temporary splinting and casting. These interventions may be prescribed either as more efficacious and
appropriate in achieving the treatment goals or to supplement and reduce the demands required of an orthosis. However, children with CP are frequently prescribed orthoses. A
follow-up study of a population of children between 5 and 16
years old demonstrated that half the children were prescribed
some orthosis in a 9-month period.12 This study is likely to
have underestimated orthotic prescription, because the study
period was shorter than the average time (10 months) in
which some children outgrow their orthoses.13
Whatever the treatment goals and design of orthosis selected, a family-centered approach will encourage appropriate
use of an orthosis within the prescribed treatment regimen.
The health care team, including the orthotist, must therefore
be well coordinated, work in partnership with the family,
provide adequate general and specific information about the
condition and the role of the prescribed orthosis, and support
the family to ensure the orthosis is used correctly.14

ORTHOTIC PRESCRIPTION
Following the earlier recommendation to distinguish the
needs of the prestanding, standing, and walking child, this
review will also attempt to describe the appropriate orthotic
management of children with CP with reference to the GMFCS.

PRESTANDING
GMFCS Level V, Level IV up to Age 6 Years, and
Level III Before Age 2 Years
Prestanding children will spend all their time in either lying
or sitting postures. Based on earlier work to develop systematic assessment protocols,15 the Chailey scales of levels of
ability in lying, sitting, and standing provide another framework for assessing the progress of children with postural
impairments.16 Achieving the sequence of postural tasks set
out in the Chailey scales requires the child to accomplish
discrete improvements in motor development and mastery of
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balance and coordination. The acquisition of skills or alternatively the provision of postural management aids, which
enable independent lying, sitting, and standing, can free the
senses and upper limbs from stabilizing the body, promoting
activities of dexterity and oromuscular function, thereby facilitating cognitive and social development. Although lying
supports and seating systems are in principle orthoses because they apply forces to the body to compensate for the
impairment, they are beyond the scope of this article because
they are forms of assistive technology not usually supplied
through the orthotic clinic. The children considered in this
section are the most severely limited and will usually have
bilateral involvement and spastic type CP.

Scoliosis
As stated earlier, children with CP who are more limited in
their activities are at greater risk of contractures and therefore deformities. Children with lower levels of ambulation,
corresponding to children classified with GMFCS levels IV
and V, are at greater risk of scoliosis.17 Scoliosis also seems to
be aggravated by the effects of gravity when affected persons
are artificially placed in the sitting position.17 Rigid plastic
thoracolumbar sacral orthoses (TLSOs) may reduce spinal
curvature and improve sitting ability while the orthosis is
worn18; however, TLSOs are unlikely to alter the rate of
progressive deformity.19 For children with large structural
scoliosis, surgical stabilization may be the more realistic
intervention to offer.
When casting for spinal orthoses (TLSOs), it is desirable to
remove the deforming axial effects of gravity. Because the
treatment goal is to enable a comfortable and functional
sitting posture, overcorrection may not be indicated. Tight
hamstrings, as demonstrated by a reduced popliteal angle,
can reduce the lumbar lordosis by posteriorly tilting the
pelvis (sometimes called sacral sitting).20 Children with poor
levels of sitting ability may also demonstrate excessive forward trunk leaning or thoracic kyphosis. Spinal orthoses may
prevent forward leaning, and one study has suggested that
the improved positioning achieved with a spinal orthosis may
in fact improve pulmonary functioning.21

JPO Journal of Prosthetics and Orthotics

controlling the position of the center of gravity and stabilizing the trunk as a single segment can be combined with hip
abduction orthosis providing a stable base. Hip abduction
spinal orthoses (HASOs) may be used in conjunction with
wheelchair seating systems or as alternatives to the wheelchair, allowing the child to sit in regular furniture. The HASO
consists of a bivalved, custom-made plastic thoracic-lumbarsacral orthosis, closely molded around the waist and pelvis,
connected to thigh cuffs with an orthotic hip joint that can be
locked at 90 of hip flexion23 (Figure 1). In this orthosis,
maximum external control of sitting posture is provided.
Because the same hip joint can also be locked with the hip
extended straight, the HASO can be useful for all the activities of lying, sitting, and standing.24,25 It is also worth noting
that although these HASOs will preferably hold the child in a
symmetrical posture, hip adduction deformities must be accommodated. Therefore, it may be necessary to provide an
asymmetrical hip position to maintain neutral pelvic posture.
In some seating systems, knee blocks are additionally used to
apply an axial force along the femur to the hip in a further
effort to prevent pelvic rotation.22 Despite the efficacy of the
HASO as a sitting orthosis, there is not yet evidence that it
can alter the natural history of progressive hip migration and
subluxation. Surgery may be necessary if painful subluxation
is limiting activities. A similar metal and leather design can
be fabricated using the same orthotic hip joint.26 However,
the efficacy of the conventional nonmolded design is under-

Hip Subluxation
The incidence of hip subluxation and dislocation is also
associated with greater activity limitations. Hip dislocation
requiring treatment before age 5 years was observed more
commonly in children with bilateral spastic CP who were
nonambulant compared with those who could walk 10 steps
by age 30 months22 (that perhaps excludes children in
GMFCS Levels III to I).
Orthoses can be used to abduct and flex the hip joint to
increase containment of the femoral head in the acetabulum
and stretch hip adductor muscles. Abducting the hips to
increase the size of the base of support and anterior tilting of
the pelvis, so that the center of gravity of the upper body falls
within the support area, also greatly improves sitting stability. For non ambulant children, the benefits of the TLSO in
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Figure 1. Hip abduction spinal orthoses (HASOs) consist of a bivalved, custom-made plastic thoracic-lumbar-sacral orthosis to stabilize the trunk as a single segment combined with hip abduction to
provide a broad stable base.
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mined by its limited control of the pelvis and multisegmental

trunk and will usually require a separate spinal orthosis.

Postoperative Hip Orthoses

Traditionally, after hip reconstruction surgery for children
with CP, hip spica casts have been applied and set at 30 of
unilateral hip abduction (combined 60 angle) and 30 of hip
flexion. Hip spicas take considerable time to apply at the end
of an often already lengthy surgery; preclude visual inspection of the surgical wounds during the postoperative period;
and can cause complications such as pressure sores. Other
disadvantages of hip spicas are the need for intensive physiotherapy and usually hospital readmission to regain ranges
of hip and knee joint motion that will have stiffened from
immobility in the cast. The use of an orthosis in these
instances may overcome some of the complications associated with using hip spica casts. The most suitable design in
these instances includes a pelvic section connected to the
thigh cuffs with an orthotic joint that allows incremental
adjustment of flexion and abduction that can be adjusted and
locked in the selected position (Figure 2).

Orthotic Management of Children with Cerebral Palsy

shortening, or both. Mobile equinovalgus and equinovarus ankle

foot deformities can be corrected during the mold taking and
cast rectification process and the position maintained using
close fitting rigid AFOs. Fixed deformities, however, must be
accommodated in their best corrected posture. Persistent ankle
and knee deformities secondary to spasticity may benefit from
intramuscular injections of botulinum A toxin to weaken spastic
muscles, often combined with short periods of serial casting to
facilitate ongoing management in orthoses. Maintaining reasonable foot and ankle posture will enable more comfortable posture in seating systems by allowing some of the weight of the
lower limbs to be supported by footplates. If profound fixed ankle
and foot deformities become established, fitting of ordinary
shoes can become a problem and custom-made footwear may be
necessary.

Upper Limb Management

Prestanding children will spend much of their time sitting and

are therefore predisposed to contractures of the muscles of the
lower limb. Many of the major muscles around the hip, knee,
and ankle actually cross two joints. For instance, the major bulk
of the calf muscle is the gastrocnemius, which crosses both the
ankle and knee. To provide an efficient stretch of the gastrocnemius, preventing plantar flexion must be augmented with an
orthosis to extend the knee. This may be achieved simply by
simultaneously using a rigid ankle foot orthosis (AFO) and a
stiffened fabric knee gaiter for short periods. Deformities of the
hind- and mid-foot can develop when the range of dorsiflexion
available at the ankle is reduced either by spasticity, muscle

Inadequate fine motor control and coordination may impair manual dexterity and may lead to muscle shortening
and reduced ranges of movement at the elbows, wrists, and
fingers. Children with bilateral spastic CP may be more
affected in their lower limbs with relatively useful function
in the upper limbs (sometimes called diplegia), or have
four limb (total body) involvement. The principles of orthotic management are the same as in the lower limbs
(that is, to stretch tight muscles, sometimes in combination with botulinum A toxin injection and serial casting).
Occasionally wrist hand orthoses (WHOs) may also be
employed to enable or improve hand function. The prescription of functional WHOs remains controversial but
may be useful to enable or improve hand function in
conjunction with occupational therapy regimens to facilitate training in skills of dexterity (Figure 3).

Figure 2. An orthotic joint that allows incremental adjustment of

hip flexion and abduction can be incorporated into an orthosis as an
alternative to a hip spica cast after hip reconstruction surgery.

Figure 3. A dorsal wrist hand orthosis (WHO) with palmar bar and
elastic Velcro straps stabilizes wrist extension enabling the child to
focus on dexterity skills.

Lower Limb Deformities

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STANDING
GMFCS Level II Before Age 2 Years, Level III After
Age 2 Years, and Level IV After Age 4 Years
The objectives of orthotic management for the standing child
are the same as for the prestanding child, with the additional
goal of facilitating an efficient upright posture with the minimum appropriate external support. Standing, even for the
nonambulant child, may be beneficial for the body structure
by increasing bone density.27 The activity of standing is also
important for stretching muscles and other periarticular tissues and to allow children to experience the world from the
same eye-level as their peers.28 The level of each childs
individual activity limitation will necessarily determine the
degree and type of external support required. Clinical examination should therefore additionally include appraisal of the
standing posture and balance assessment.
For most impaired children who will achieve standing
(GMFCS Level IV), a hip knee ankle foot orthosis (HKAFO)
will be required to maintain an upright posture, simulating
Chailey Level 4 for standing ability. Two three-point force
systems are used to prevent hip and knee flexion: applied to
the anterior chest, posterior sacrum, anterior knees, and
posterior heels. This may be fixed to a broad support base as
a standing frame and used with a tray at an appropriate
height. If children are able to generate adequate hip extension power, then the chest strap can be removed for short
periods. Children will often require support of the ankle and
foot to provide stability at the foot-floor interface during
standing. Spastic equinus and any secondary hind- or midfoot valgus or varus can either be corrected or accommodated
in rigid AFOs. Heel wedges can be used to alter the inclination of the lower leg relative to the floor to accommodate
fixed flexion of the hips and knees or fixed equinus.
Children who are able to pull themselves upright and
maintain standing independently by holding on to an anteriorly placed piece of furniture may still benefit from some
external support (GMFCS Level II before age 2 years, Level III
after age 2 years). Orthoses that restrict ankle motion can be
used to provide a stable base and control the line of action of
the ground reaction force around the hip and knee so that
training and strengthening can be targeted at proximal muscles.10
In a study of standing balance, the center of pressure
under the foot was shifted more anteriorly for children with
spastic equinus than for normal children, as would be expected.29 Using footwear and AFOs that resisted plantar flexion
enabled the children to shift the center of pressure more
posteriorly but had little effect on lateral sway characteristics.
Another small study compared four children with CP with
four healthy children during perturbed standing balance
while barefoot and with rigid and spiral graphite AFOs.30 This
study demonstrated the difficulty children with CP have in
recruiting muscles to maintain balance and indicated that
rigid AFOs can impose further difficulties by removing the
postural adjustments that can be made at the ankle. In other
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studies that have examined the activity of moving from sitting to standing, children with CP and spastic equinus who
were slower than healthy children performed the task faster
with either rigid or hinged AFOs (perhaps GMFCS Levels II
and III). However, similar children who were within 1 standard deviation of the range of normal children in achieving
the task barefoot were slower when using either design of
orthosis (perhaps GMFCS Level I).31 Therefore, permitting
small amounts of movement at the ankle may enhance standing balance and enable the child to move from sitting to
standing more easily. Children who achieve independent
standing can then focus on developing skills of walking,
perhaps requiring ongoing assistance of orthoses and walking
aids (GMFCS Levels III and IV).

WALKING
GMFCS Levels I, II, and III After Age 2 Years and
Level IV After Age 4 Years
Approximately two thirds of children with CP will achieve
some level of walking ability.32 The objectives of orthotic
management for the walking child are the same as for the
prestanding and standing child, with the additional goal to
enable the child to attain an efficient and purposeful gait. In
addition to the information required in the clinical examination of prestanding and standing child, an assessment of the
childs gait is necessary. The gait of children with spastic type
CP is generally repeatable from step to step. However, children with ataxic or dyskinetic types of CP may be more
variable and less predictable. Gait analysis requires a systematic approach to describe the patterns of joint motion and
identify factors that cause pathological movements. The difficulty in analyzing the gait of children with CP is that the
impairment causes gait deviations in each of the sagittal,
coronal, and transverse planes and commonly involves the
hip, knee, and ankle joints.
Winters33 classification for children with spastic hemiplegia identified four distinct patterns with increasing distal to
proximal involvement. For Winters Type 1 hemiplegia, which
presents as equinus only in swing phase, either a posterior
leaf spring or hinged AFO with a plantar flexion stop may
improve foot ground clearance. For Winters Type 2 hemiplegia, when equinus persists in stance and swing phase and the
knee is hyper-extended during stance, a rigid AFO is recommended. For Winters Types 3 and 4, when additional knee
and hip pathology exists, orthotic management is insufficient
and orthopaedic surgery is indicated.
Sutherland and Davids34 identified four patterns of knee
motion in spastic diplegia. In combination with Winters
classification,33 these patterns have been used to create algorithms for physical management that combine appropriate
use of spasticity, musculoskeletal and orthotic interventions.35 Recommendations for orthotic intervention to improve gait efficiency are usually based on the integrity of the
plantarflexion-knee extension couple during stance phase.35
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foot complex and the knee joint to maintain the ground

reaction force (GRF) just in front of the knee during stance
phase. It requires the ankle and foot to be stable, leading in
the line of progression and the gastrocnemius and soleus
muscles functioning to control tibial advancement.11
Children with spastic type CP commonly walk with ankle
equinus.11,33,36 Making initial contact with the forefoot during walking will usually cause the line of action of the GRF to
pass well in front of the knee and hip joints, causing an
excessive external knee extension moment, perhaps hyperextension (or back-kneeing), and a flexion moment around the
hip. Rigid AFOs that prevent plantarflexion and have been
appropriately tuned can alter the line of action of the GRF to
reduce the resulting abnormal moments around the knee and
hip joints, prevent knee hyperextension and increase hip
extension9,10 (Figure 4).
For children with more severe impairment, spasticity of
proximal muscles will cause the knee and hip joints to remain
flexed during stance.11,33 When the GRF passes behind the
knee, the increased external flexion moment will cause excessive knee flexion and crouching. AFOs that prevent dorsiflexion at the ankle can prevent knee flexion during stance by
realigning the GRF in front of the knee37 (Figure 5). However, whereas these orthoses are effective for paralyzed limbs,
the presence of spastic or fixed flexion at the knee and hip
joints means that other interventions are required to render
these orthoses effective in children with CP.38 We routinely
use anterior GRF AFOs, extending proximally to the tibial
tubercle, in the 6 months postmultilevel surgery to protect
the weakened muscles and enable early standing and walking.
In either of the above situations, the rigid lever of the
ankle and foot must also cope with premature and prolonged

Figure 4. A: Making initial contact with the forefoot, secondary to

spastic equinus, creates abnormal movements around the knee and
hip joints, causing knee hyperextension. B: Rigid AFOs that prevent
plantarflexion can alter the line of action of the GRF to reduce the
external moment. C: Depending on the pitch of the shoe, fine tuning
with heel wedges can further enhance the efficacy of the orthosis by
tilting the knee joint anterior to the GRF.
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Orthotic Management of Children with Cerebral Palsy

Figure 5. A: When the GRF passes posterior to the knee, the external
movement will cause excessive knee flexion and crouching. B: AFOs
that prevent dorsiflexion at the ankle can prevent knee flexion
during stance by realigning the GRF in front of the knee to assist
extension.

external dorsiflexion moment. The multisegmental structure

of the ankle and foot may buckle due to the applied forces,
causing hindfoot eversion or inversion and mid-foot collapse.
In these circumstances, apparent dorsiflexion will occur at
the expense of the structure of the ankle and foot. Therefore,
when the integrity of the ankle and foot is insufficient to
maintain a rigid lever, and the hind and mid-foot is at risk of
deformity, it may be as important to prevent dorsiflexion as
well as plantar flexion using a rigid AFO.
Because clinicians are aware that restrictive orthoses may
impose additional activity limitations, orthoses should continue to facilitate, where possible, normal patterns of joint
motion. Many studies have therefore attempted to compare
the efficacy of rigid, hinged, PLS, and supramalleolar AFOs. A
recent review of the efficacy of orthoses for children with CP
could only conclude that preventing plantar flexion improved
gait efficiency.39 Preventing plantar flexion has been shown
to improve stability in stance phase,40 clearance in swing
phase,41 prepositioning in terminal swing42 and to increase
step length and walking speed.43 There is a suggestion that
preventing plantarflexion may also improve energy expenditure based on oxygen consumption.44
There is no evidence to support any tone-reducing effect
on gait from orthoses that incorporate specially molded footplates.45 Therefore, the prescription of supramalleolar orthoses that provide no leverage to prevent plantar flexion would
seem to offer little benefit in the goal to improve gait efficiency. However, supramalleolar and foot orthoses may be
beneficial to children with dyskinetic or ataxic types of cerebral palsy whose sagittal plane gait deviations are an essential
mechanism for achieving ambulation or indeed for children
whose equinus during gait has been improved after surgery.

Coronal and Transverse Plane Gait Deviations

Gait deviations in the coronal and transverse planes are more
difficult to distinguish than those in the sagittal plane using
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only observational gait analysis. Leg-length discrepancy

(LLD) in children with CP, which is associated with hemiplegia, asymmetrical involvement, or hip subluxation, causes
either compensatory excessive flexion of the longer limb or
pelvic obliquity. Pelvic obliquity caused by LLD results in
true hip adduction on the longer limb and hip abduction of
the shorter side and can be corrected using a shoe raise.
Pelvic rotation, torsional abnormalities, or foot deformities can change the angle of the foot in relation to the line of
progression (in- or out-toeing). Apparent rather than true hip
adduction occurs when internal rotation is seen in conjunction with flexion, causing the knees to come together when
viewed in the coronal plane (sometimes called scissor gait).
This occurs frequently in children with CP because of persistent skeletal anteversion of the femur,11,46 and for ambulant children is more common than true hip adduction or
internal rotation at the hip joint. Hip abduction orthoses for
ambulant children may therefore be of little benefit.
Although it may be possible to harness shear forces from
the skin and the shape of the soft tissues to gain some
rotational control using a molded thigh cuff, in general,
rotational control of the hip joint using orthoses requires
extension to the foot. Orthoses incorporating a flexible torque
cable within the thigh segment of a HKAFO or elastic bands
wound around the limb attached to AFOs create active rotational forces and can alter the foot progression angle.47 However, when the cause of internal hip rotation is persistent
femoral anteversion or spasticity, twister orthoses are not
advised because the applied torque can lead to excessive
strain on the soft tissues of the knee joint. Therefore, torsional deformities usually require a surgical solution. In- or
out-toeing may also result from excessive pelvic rotation or
foot deformity when there may be no torsional component in
the long bones. Mobile deformities of hindfoot inversion with
associated forefoot adduction and hindfoot eversion with associated forefoot abduction can be corrected during the casting process and controlled using AFOs. Pelvic rotation, in
which the child leads with the less impaired limb, is part of
the primary neurological impairment and cannot be influenced by orthotic management.

EVIDENCE TO SUPPORT ORTHOTIC

INTERVENTION
To date, all published studies examining the efficacy of orthoses for walking children with CP have included small
numbers of children, and all but one48 have used withinsubject comparison research designs. The evidence to support specific orthotic interventions for children with CP remains to be demonstrated using more robust research
methods, such as randomized controlled trials with appropriate follow-up periods. The difficulties in mounting randomized controlled trials in this population are well recognized, in that CP is a heterogeneous condition with a wide
range of neurological impairment.49,50 Recruiting groups of
children with comparable baseline characteristics into a trial
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can be perceived as an obstacle. The SCPE classification2 and

the GMFCS4 now enable researchers to balance groups of
children of comparable impairments and activity limitations.
However, clinical trials that would demonstrate any moderate
but statistical significant differences between treatment
groups would require multicenter collaboration to recruit
enough subjects.51 There is also the difficulty of ascertaining
clear and simply measured outcomes. Separate treatment
goals and outcome measures must therefore be defined in the
body structure and activity dimensions.1,52 Other challenges
to designing clinical trials are the inconsistent arrangements
for the organization and delivery of orthotic services and the
confounding effects of associated interventions. Perhaps the
most difficult problems to overcome are the strongly held
views of clinicians and families on the merits of different
orthotic interventions that prevail in the absence of good
evidence.

CONCLUSIONS AND RECOMMENDATIONS

The benefits of most orthotic interventions used in physical
management regimens for children with cerebral palsy remain controversial. There continues to be significant variation in the orthotic management of children with CP among
treatment centers as a result of conflicting treatment paradigms.12 If there is uncertainty that the defined outcomes of
orthotic management will be achieved, then there is an
ethical responsibility for the individual clinician to inform
families of that uncertainty and a justification to offer recruitment into a trial that may answer the question in the
longer term. However, to overcome the biases of individual
clinicians, consensual equipoise among health care professionals based on the prevailing controversy over different
designs of orthoses must be recognized and addressed using
robust research methodologies.53
This review has attempted to use the GMFCS as a framework for distinguishing treatment goals for orthotic management for children with CP. Health care pathways and physical
management algorithms based on valid and reliable classification systems such as the GMFCS would help us identify the
benefits and shortcomings of interventions for children with
a broad spectrum of activity limitations. Certainly, the outcomes of orthotic intervention to prevent deformities must
be measured against overcoming activity limitations. Therefore the inter-relationship of these key dimensions of health
must be explored further using sound scientific principles.

REFERENCES
1. World Health Organization. International Classification of
Functioning, Disability and Health (ICF). Geneva: WHO; 2001.
2. Surveillance of cerebral palsy in Europe. a collaboration of
cerebral palsy surveys and registers (SCPE). Dev Med Child
Neurol. 2000;42:816 824.
3. Graham HK. Painful hip dislocation in cerebral palsy. Lancet.
2002;359:907908.
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JPO Journal of Prosthetics and Orthotics

Orthotic Management of Children with Cerebral Palsy

4. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi

B. Development and reliability of a system to classify gross
motor function in children with cerebral palsy. Dev Med Child
Neurol. 1997;39:214 223.

21. Leopando MT, Moussavi Z, Holbrow J, Chernick V, Pasterkamp

H, Rempel G. Effect of a Soft Boston Orthosis on pulmonary
mechanics in severe cerebral palsy. Pediatr Pulmonol. 1999;28:
5358.

5. Kennes J, Rosenbaum P, Hanna SE, Walter S, Russell D, Raina

P, Bartlett D, Galuppi B. Health status of school-aged children
with cerebral palsy: information from a population-based sample. Dev Med Child Neurol. 2002;44:240 247.

22. Scrutton D, Baird G, Smeeton N. Hip dysplasia in bilateral

cerebral palsy: incidence and natural history in children aged 18
months to 5 years. Dev Med Child Neurol. 2001;43:586 600.

6. Condie DN, Meadows CB. Conclusions and recommendations.

In: Condie DN, Meadows CB, eds. Report of a Consensus Conference on the Lower Limb Orthotic Management of Cerebral
Palsy. Copenhagen: International Society of Prosthetics &
Orthotics; 1995:1519.
7. Tardieu C, Lespargot A, Tabary C, Bret MD. For how long must
the soleus muscle be stretched each day to prevent contracture?
Dev Med Child Neurol. 1988;30:310.
8. Charlton P, Ferguson D, Peacock C, Stallard J. Preliminary
clinical experience of a contracture correction device. Prosthet
Orthot Int. 1999;23:163168.
9. Meadows CB. The influence of polypropylene ankle-foot orthoses on the gait of cerebral palsied children. [PhD thesis]. Strathclyde, UK: University of Strathclyde, 1984.
10. Butler PB, Thompson N, Major RE. Improvement in walking
performance of children with cerebral palsy: preliminary results. Dev Med Child Neurol. 1992;34:567576.
11. Gage JR. Gait Analysis in Cerebral Palsy. London: MacKeith
Press; 1991.
12. Morris C, Newdick H, Johnson A. Variations in the orthotic
management of cerebral palsy. Child Care Health Dev. 2002;28:
139 147.
13. Supan T, Hovorka C. A review of thermoplastic ankle-foot orthoses adjustments/replacements in young cerebral palsy and
spina bifida patients. J Prosthet Orthot. 1995;7:1522.
14. King G, King S, Rosenbaum P. Interpersonal aspects of caregiving and client outcomes: a review of the literature. Ambul
Child Health. 1996;2:151160.
15. Hallet R, Hare N, Milner AD. Description and evaluation of an
assessment form. Physiotherapy. 1987;73:220 225.
16. Poutney T, Mulcahy C, Clarke S, Green E. The Chailey Approach
to Postural Management. Birmingham, UK: Active Design Ltd.;
2000.
17. Madigan RR, Wallace SL. Scoliosis in the institutionalized cerebral palsy population. Spine. 1981;6:583590.
18. Terjesen T, Lange JE, Steen H. Treatment of scoliosis with
spinal bracing in quadriplegic cerebral palsy. Dev Med Child
Neurol. 2000;42:448 454.
19. Miller A, Temple T, Miller F. Impact of orthoses on the rate of
scoliosis progression in children with cerebral palsy. J Pediatr
Orthop. 1996;16:332335.
20. McCarthy JJ, Betz RR. The relationship between tight hamstrings and lumbar hypolordosis in children with cerebral palsy.
Spine. 2000;25:211213.
Volume 14 Number 4 2002

23. Drake C, Boyd R. The design and manufacture of a thermoplastic hip abduction/spinal orthosis for bilateral non ambulant
cerebral palsy children [abstract]. ISPO UK News. 1993;
Summer:2526.
24. Bower E. Hip abduction and spinal orthosis in cerebral palsy (an
alternative to the use of a special seating, lying boards and
standing frames). Physiotherapy. 1990;76:658 659.
25. Boyd R, Drake C. Effectiveness of the hip abduction and spinal
orthosis for postural management in a group of non ambulant
bilateral cerebral palsy children [abstract]. ISPO UK News. 1993;
Summer:26 27.
26. Hopkins BP. The development of a symmetrical hip orthosis.
Physiotherapy. 1992;78:428 432.
27. Chad KE, Bailey DA, McKay HA, Zello GA, Snyder RE. The effect
of a weight-bearing physical activity program on bone mineral
content and estimated volumetric density in children with spastic cerebral palsy. J Pediatr. 1999;135:115117.
28. Stuberg WA. Considerations related to weight-bearing programs
in children with developmental disabilities. Phys Ther 1992;72:
35 40.
29. Carmines DV, Granata KP, Abel MF. Effects of dynamic ankle
foot orthoses upon static balance in children with cerebral palsy
[abstract]. Gait Posture. 2000;11:160.
30. Burtner PA, Woollacott MH, Qualls C. Stance balance control
with orthoses in a group of children with spastic cerebral palsy.
Dev Med Child Neurol. 1999;41:748 757.
31. Wilson H, Haideri N, Song K, Telford D. Ankle-foot orthoses for
preambulatory children with spastic diplegia. J Pediatr. 1997;
17:370 376.
32. Pharoah PO, Cooke T, Johnson MA, King R, Mutch L. Epidemiology of cerebral palsy in England and Scotland, 1984 9 Arch
Dis Child Fetal Neonatal Ed. 1998;79:F21F25.
33. Winters TF Jr, Gage JR, Hicks R. Gait patterns in spastic hemiplegia in children and young adults. J Bone Joint Surg Am.
1987;69:437 441.
34. Sutherland DH, Davids JR. Common gait abnormalities of the
knee in cerebral palsy. Clin Orthop. 1993;288:139 147.
35. Rodda J, Graham HK. Classification of gait patterns in spastic
hemiplegia and spastic diplegia: a basis for a management
algorithm. Eur J Neurol. 2001;8(Suppl. 5):98 108.
36. Goldstein M, Harper DC. Management of cerebral palsy: equinus
gait. Dev Med Child Neurol. 2001;43:563569.
37. Saltiel J. A one-piece laminated knee locking short leg brace.
Orthot Prosthet. 1969;23:68 75.
157

Morris

JPO Journal of Prosthetics and Orthotics

38. Harrington ED, Lin RS, Gage JR. Use of the anterior floor
reaction orthosis in patients with cerebral palsy. Orthot Prosthet. 1984;37:34 42.
39. Morris C. A review of the efficacy of lower-limb orthoses used for
cerebral palsy. Dev Med Child Neurol. 2002;44:205211.
40. Miller NH, Chambers C. Dynamic versus standard AFOs: a
comparison of gait parameters [abstract]. Orthop Trans. 1999;
22:452.
41. Ounpuu S, Bell KJ, Davis RB 3rd, DeLuca PA. An evaluation of
the posterior leaf spring orthosis using joint kinematics and
kinetics. J Pediatr Orthop. 1996;16:378 384.
42. Romkes J, Brunner R. Comparison of a dynamic and a hinged
ankle-foot orthosis by gait analysis in patients with hemiplegic
cerebral palsy. Gait Posture. 2002;15:18 24.
43. Abel MF, Juhl GA, Vaughan CL, Damiano DL. Gait assessment of
fixed ankle-foot orthoses in children with spastic diplegia. Arch
Phys Med Rehabil. 1998;79:126 133.
44. Maltais D, Bar-Or O, Galea V, Pierrynowski M. Use of orthoses
lowers the O2 cost of walking in children with spastic cerebral
palsy. Med Sci Sports Exerc. 2001;33:320 325.
45. Crenshaw S, Herzog R, Castagno P, Richards J, Miller F, Michaloski G, Moran E. The efficacy of tone-reducing features in
orthotics on the gait of children with spastic diplegic cerebral
palsy. J Pediatr Orthop. 2000;20:210 216.

46. Bleck EE. Orthopaedic Management in Cerebral Palsy. London:

MacKeith Press; 1987.
47. Nuzzo RM. Dynamic bracing: elastics for patients with cerebral
palsy, muscular dystrophy and myelodysplasia. Clin Orthop.
1980;148:263273.
48. Evans C, Gowland C, Rosebaum P. The effectiveness of orthoses
for children with cerebral palsy [abstract]. Dev Med Child Neurol. 1994;36(Suppl. 70):26 27.
49. McConachie HR. Conceptual frameworks in evaluation of multidisciplinary services for children with disabilities. Child Care
Health Dev. 1999;25:101113.
50. Davidson LL. Evaluating child disability programmes: the role
of commissioners. Child Care Health Dev. 1999;25:129 139.
51. Yusuf S, Collins R, Peto R. Why do we need some large, simple
randomized trials? Stat Med. 1984;3:409 422.
52. Butler C, Chambers H, Goldstein M, Adams R, Samson-Fang L,
Darrah J, ODonnell M, Leach J, Edgar T, Abel M, Msall M.
AACPDM methodology for developing evidence tables and reviewing treatment outcomes research. 1999. http://www.aacpdm.org/committees/BUT_guide.pdf
53. Freedman B. Equipoise and the ethics of clinical research.
N Engl J Med. 1987;317:141145.

2003 Academy Learning Series

Academy Annual Meeting and
Scientific Symposium

CEC 1-2003 Regional Conference

March 19-22,
Sheraton San Diego, San Diego, CA

June 6-7,
Las Vegas, NV, In conjunction with the
Phoenix Chapter

Spring Exam Preparation Seminar

CEC 2-2003 Regional Conference

April 11-12,
Northwestern University P&O Center,
Chicago, IL

July 24-25,
Austin, TX, In conjunction with the
Texas Chapter

Advanced Training Course

Advanced Training Course

May 1-3,
Protecting the Patient from Product
Failure and Preventing Malpractice
Lawsuits - Better Material Science and
Prosthetic/Orthotic Design
Chicago, IL

September 18-20,
Stance Control
Chicago, IL

One-Day Seminar on the O&P

Management of the Upper-Limb
Patient
October 3

One Day Seminar on Practice

Management
October 4
Both in Chicago, IL

Fall Exam Preparation Seminar

October 17-18, 2003,
Northwestern University, Chicago, IL

Advanced Training Course

Date TBA,
Lower Limb Biomechanics for
Prosthetists and Orthotists
Chicago, IL

Visit the Academys website (www.oandp.org) for program details as they develop.

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