Orthosis Management in Children With Cerebral Palsy

If you encounter a pediatric patient with cerebral palsy chances you may find the solution to orthotics treatment with some customized adjustment. To make a truly useful orthoses for a child with cerebral palsy you may also need to know body mechanics and kinematics.

Spastic cerebral palsy is the common type cerebral palsy, found approximately in 80% of children with the disability. Although orthotics intervention has adjusted in small ways to accommodate new research in the body mechanics and gait, the overall goals are the same. The goal of lower limb orthotic management of cerebral palsy is to correct and/or prevent deformity; to provide a base of support to facilitate training in skills and to improve the efficiency of gait. Other goals include increasing range of motion, maintaining or improving levels of function and stability.

Maintaining length as the bone grow, and preventing and overcoming some the secondary effects of the disability leading into adulthood, no single treatment is appropriate for every child, but it is generally agreed that sooner the intervention is started the better the outcome. Orthoses prescribed to prevent or correct the deformities can pose addition activity limitation by restricting movement . normal functional development can be impeded by impairment of coordination and movement.

Orthoses can maintain optimum biomechanical aligment of body segments enable children to overcome activity limitations by focusing training on unrestricted parts for their bodies over which they have better control.

A multidisciplinary team including an orthotist, physical therapist and an orthopedist can advance a child with cerebral palsy along the continuum of care throughout his development. This team, coordinating with a family centered approach to care, should encourage optimal use of an orthosis within the prescribed treatment plan.

There are different and evolving schools of thought regarding the use of orthotic intervention. Some practitioners believe less bracing is better and that positive development can come from muscle stretching, training and strengthening exercises. There is a trend toward making below-the-knee only orthoses and using flexible AFOs to maximize gait and performance.

It is important to remember that providing orthotic care to this patient population does not follow a one-size-fits-all approach. An orthosis must fit well, and control the ankle, forefoot and hindfoot. Total contact is important because of the deviations in planes of the foot. A loose brace may cause skin breakdown; an orthosis that is dorsiflexed may cause discomfort and decreased function in a child who doesn't have adequate dorsiflexion range of motion.

Patients with spasticity may have inherent body weakness that affects their inability to control their muscles. Strengthening those muscles, once thought to increase plasticity, is now a critical part of a multidisciplinary approach to treatment.

We still have to use AFOs. Neutral alignment reduces the power of over-powerful muscles, and gives underused and underpowered muscles a chance to increase in strength and be more effective.

AFOs that control the foot in stance and swing phase can improve gait efficiency in children with cerebral palsy. The report suggested little evidence supporting the use of orthoses for the hip, spine or upper limb. The trend toward using less rigid materials to craft AFOs allows the child more motion. Now days Light wt poly propylene materials are being used commonly, that is more comfortable to child.

Traditionally there has been a lot of use of 90· angle of the ankle in the AFO, when that might not always be the optimal alignment of the foot relative to the shank. That may change the bony alignment of the foot, and the child may not be extending their knee fully in gait. They might walk with a flexed knee gait and therefore not be stretching their calf muscles. Owen disagrees with the notion that the foot has to always be supported at 90·and that by failing to do so, the child cannot get good knee extension in gait.