Pediatric+Dynamic+AFOs

Welcome to our Wiki! The purpose of this wiki is to act as a resource for us as future clinicians in the pediatric setting with regards to treating select common pathologies with dynamic ankle-foot othoses (DAFOs). We will introduce the Goals of Bracing, some common Tests & Measures, and offer some helpful websites for reference in Bracing Guidelines. Finally, we will review the following chosen pathologies: cerebral palsy, down syndrome, muscular dystrophy and spina bifida in relation to pathological alignment or gait. How can an orthotic help, you ask? Read on.
 * Purpose Statement**

**Goals of Bracing/Outcome Measures: **
 * Prevent a deformity by encouraging proper joint alignment
 * Providing more efficiency in ambulation
 * Encourage PF to minimize excessive knee flexion
 * For those with soleus spasticity, promote DF hereby minimizing knee hyperextension and allowing knee flexion
 * For patients with low tone or muscle weakness, the AFO should provide support to keep them from falling into pronation
 * In minimally ambulatory patients, keep ankle in a position of optimal comfort and alignment while maintaining ankle ROM
 * For patients with a crouched gait due and instability, promote better posture and support in stance and swing phases

**Tests & Measures ** Goniometer measurements SPATs:
 * Take R1 (AOC) & R2 (static) values (popliteal, gastroc, soleus, & abductor).
 * Normal values are: 25° popliteal, 10° gastroc, 20° soleus, & 45° abduction (Ultraflex.com)
 * Point of spasticity can be confirmed with an EMG (Van den Noort).

** Bracing Guidelines ** Specific AFO manufacturer's websites will usually have a bracing guidelines document. They may include specific measurements to take for patients considering an orthotic.
 * Cascade’s bracing guidelines can be found here: []. They also have a downloadable format on the right side of that page.
 * Sure Step is another manufacturer that has a host of resources online. Guideline measurement forms can be retrieved at [].
 * Ultraflex Guides are here [].

** Cerebral Palsy ** ** Pathology ** Cerebral Palsy (CP) is a group of nervous system disorders that effect one’s ability to control posture and movement. There are several forms of CP including spastic, dyskinetic, ataxic, hypotonic, and mixed. It can involve one or both sides of the body, the upper and/or lower extremities, and varies in severity from mild to maximal. It is caused by brain trauma at any point during the brain’s development, from damage in the womb to a difficult delivery, up through the first two years of life (A.D.A.M.). The most common type is spastic CP and will our focus. The triad used to determine the presence of spasticity is increased deep tendon reflexes, increased tone, and clonus. The Gross Motor Function Measure (GMFM) is used to determine the stage of cerebral palsy and estimate the gross motor ability of the child.

This score sheet is a tool to evaluate and calculate the GMFM. [|GMFM Score Sheet]

The Center for Childhood Disability Research has a detailed staging system that incorporates the GMFM. It classifies the child’s level based on motor abilities and development and has been adjusted for age. For the detailed chart, see the following link. [|Spastic CP Classification]

** How does CP effect gait? ** Gait abnormalities can negatively affect the child’s mobility, independence, daily functioning, and in turn his/her participation in activities and society. Children with cerebral palsy have muscle stiffness and possibly weakness or paralysis, which causes their gait to be unstable, asymmetric, and highly energy inefficient. They will often walk on their toes, have a scissoring gait pattern, keep their arms tucked in at their sides, and have inward turned knees (A.D.A.M.). The joint contractures and muscle tightness can lead to compensations during gait, which can lead to deformities (Figueiredo, et al). The most common deformity is equinus, excessive plantarflexion with lack of dorsiflexion causing toe walking and difficulty clearing the foot during swing (Hayek, et al). Specific abnormalities depend on the physical presentation of the child and which muscle are effected. media type="youtube" key="-MMtyzeYVmM" height="315" width="560"

[|Biomechanical Analysis of CP Gait] [|Child's Gait with CP]

** AFOs for children with CP ** AFOs help to assist in foot clearance at swing, correct foot pre-positioning at initial contact, provide stability in stance phase, and reduce energy expenditure. They can also help prevent initial or progression of deformity. In their systematic review, Figueiredo, Ferreira, Maia Moreira, Kirkwood, and Fetters determined AFOs were able to positively effect passive and active ankle ROM and gait kinetics and kinematics. They found AFOs to significantly improve passive ankle dorsiflexion ROM with both knee flexion and extension and to decrease energy expenditure during gait. Further, AFOs improved dorsiflexion at initial contact, midstance, and swing. During initial contact, AFOs were able to improve ankle positioning by either decreasing ankle plantarflexion or increasing dorsiflexion. This also helped better position the ankle during swing and reduce equinus during midstance (Fieuiredo et al).

Hayek, et. al found some specific recommendations for fitting children for an AFO. Children who walk with a crouch may benefit from a solid AFO inducing knee extension or from a ground reaction AFO preventing excessive forward movement of the tibia. Children with excessive equines may benefit from a hinged AFO allowing dorsiflexion during stance. Posterior leaf AFOs can help conserve energy during midstance if weak plantar flexors are an issue. With the addition of an AFO, Hayek et. al found ankle dorsiflexion increased for foot clearance during swing, the foot had better position and heel strike at initial contact, and knee flexion was reduced at initial contact. However, they found no significant change in knee or hip kinematics. Overall the AFO improved stride length and gait symmetry due to more stability during stance (Hayek, et al). So the AFOs were found to be an effective intervention by this article and by the former systematic review.

The following links show various AFOs for children with CP. There is no single correct AFO for CP; each child needs to be fitted for one that will work best for him/her and that will help the child’s specific goals. When selecting an AFO, a holistic and team approach is best; the rehab team, orthotist, parent, and child should all be involved. Future needs and financial considerations should also be considered. Both these companies make AFO for children and would be good resources for finding an AFO for a child. [|Cascade DAFOs] [|SureStep AFOs]

For some additional information about Spastic CP, a resource about the care and maintenance of an AFO, and skin assessment for the child, see this link. [|CP Orthosis]

Some children may require more than just an AFO. Here is a resource for future use that can help with other adaptive equipment. [|CP Adaptive Equipment]

** Muscular Dystrophy ** __ Pathology __ Muscular dystrophy is a group of autosomal recessive disorders. The most common and most severe type is known as Duchenne muscular dystrophy (DMD), and is going to be the main focus (Muscular, 2012). DMD is an x-linked recessive disorder, mostly affecting boys, and is primarily passed through the mother (Gould & Dyer, 2011). This disorder usually begins before the age of five, and these children usually live an average of twenty years (Clark, 2012). DMD is caused by a mutated muscle gene, known as dystrophin (Gould & Dyer, 2011). The mutation causes the dystrophin to be completely absent or shortened. The mutated dystrophin causes the muscles cells to begin to degenerate and become necrotic (Gould & Dyer, 2011). The body then will begin to replace the lost muscle with connective tissue and fat (Brayden, 2012). As the disease progresses muscle function is gradually worsened (Duchenne, 2012). Cardiac and respiratory problems can also develop further increasing the severity of the disease (Duchenne, 2012).. Common signs noted early are frequent falls and Gowers sign, which is when the child affected uses their hands to climb up their legs for support when having trouble getting off of the ground (Muscular, 2012). [|Gowers Sign]

__How does muscular dystrophy affect gait?__ Initially, in children affected by DMD, the most noted muscle weakness is shown in the hips and upper leg muscles, and eventually most of the voluntary muscles will be affected (Duchenne, 2012). The progressive weakening muscles affects gait, and usually around the age of twelve the person affected will need a wheelchair (Clark, 2012). The children may walk on their toes which is often associated with lordosis and a protruding abdomen (D'Angeloa, et al.. 2009). The excessive foot plantar flexion, causing them to walk on the toes, is usually compensated by increased flexion and abduction of the hip to help the limb clear the ground. They also will have quadriceps weakness which causes the child to have a weak knee flexion moment and hyperextension of the knee late in stance to help compensate for the weak quads. During gait the stride length is reduced and step with is usually increased to help provide more support and balance (D'Angeloa, et al.. 2009).

[|Muscular Dystrophy Timeline] __AFO’s for children with DMD__

1) The **KiddieGAIT AFO** is made up of a lightweight framework that helps encourage a heel-to-toe gait pattern. The inner boot helps control the foot and the orthotic’s floor reaction frame will help with management of knee extension and knee flexion moments, add dynamic response, and help provide stability and support for the lower leg. [|KiddieGAIT AFO]

2)The Pediatric Wrap Around AFO is a dynamic AFO that helps provide support and stabilization to the foot while controlling ankle and foot alignment. It can also help to control foot drop which is associated with weakened anterior tibialis muscles from DMD. [|Pediatric Wrap Around AFO]

** Down Syndrome ** __Pathology__ Down syndrome is a genetic disorder that occurs when a baby is born with 47 chromosomes instead of the normal 46. Most often, they have an extra copy of chromosome 21. This type of Down syndrome is called Trisomy 21. One in 660 infants is born with Down syndrome, making it the most common single cause of human birth defects (Down syndrome, 2011).

Down syndrome can vary greatly from person to person, ranging from mild to severe. However, there are many physical signs that distinguish children born with this disorder (Down syndrome, 2011):
 * Small and abnormally shaped head
 * Upward slanting eyes
 * Flattened nose
 * Small ears
 * Small mouth
 * Small, wide hands with single deep crease across the palm
 * Short fingers
 * Ligament laxity
 * Decreased muscle strength
 * Decreased muscle tone

In addition to their outward appearance, children with Down syndrome also have delayed physical, mental and social development. Many never reach their normal average height and may have problems with behavior, judgment, learning, and attention span (Down syndrome, 2011).

__How does Down Syndrome affect gait?__ There are three characteristics of children with Down syndrome that affect their gait: ligament laxity, decreased muscle strength, and decreased muscle tone (Selby-Silverstein, Hillstrom & Palisano, 2001). Because of these issues, posture of the lower extremities tends to be in hip abduction and external rotation, knee hyperextension, and foot pronation and eversion (Cimolin et. al, 2010). These children learn to walk with a wide base support, hyperextended knees, and with their feet turned out. All of these are compensations for the decreased stability of their legs due to the muscle weakness, hypotonia, and ligament laxity (Winders, 2001).

Excessive pronation is one of the biggest gait issues for these children that can be addressed with an AFO. The lax ligaments in their feet do not give enough support to maintain the normal arches (Galli, Rigoldi, Brunner, Virji-Babul & Giorgio, 2008). This causes them to bear more weight on the medial sides of their feet instead of the lateral sides during push off. If they are allowed to continue bearing weight on the medial sides of their feet with every step, they will begin to develop problems which can include pain when walking and decreased endurance (Winders, 2001). __AFOs for Patients with Down Syndrome__

// Flexible Supramalleolar Orthotics (SMO): // This orthotic can be made for children with pronation secondary hypotonia and muscle weakness. It is thought to use compression to promote correct positioning of the foot during all types of gait activities, including running and jumping. In an article by Martin that looked at the effects of SMOs on postural stability in children with Down Syndrome, it is proposed that the SMO helps correct over pronation by improving the biomechanical alignment of the foot which then allows the muscles to work in a more appropriate length-tension relationship (Martin, 2004).

SureStep SMO Video

//Dynamic Ankle Foot Orthotics (DAFO)// This orthotic can also be made for children with over pronation due to ligament laxity and muscles weakness. It wraps around the entire foot, allowing for full control of the heel, midfoot, and forefoot. It has open ankle trims lines that allow for free plantarflexion and dorsiflexion, but the outer foundation is solid which provides support and stabilization of the heel (Cascade DAFO Inc., 2012).

Low Tone Pronation Video

**Spina Bifida** Spina bifida (SB) is an incomplete closure of the neural tube and spinous processes of the affected vertebra during development. It is classified into two overall categories: SB occulta (no herniation) and SB aperta (herniation). The SB aperta group is further broken down into meningocele (herniation of meninges and CSF but no neurological damage) and myelomeningocele (herniation of spinal cord, nerves and CSF) (Gould & Dyer 2011). Obviously, the patient with spinal nerve herniation has a more severe case and usually has a greater number of muscles that are affected. When SB occurs in the lumbosacral area (most common), motor and sensory deficits occur in the lower extremities and can be accompanied by impairments in the anal and urethral sphincters. Often ambulation is delayed in life (achieved between ages 2-4 most commonly) or not at all. In a study of 1500 patients, 35.5% were able to walk without an assistive device, 39.5% needed an assistive device, orthoses or both, and 22% needed a wheelchair. The loss of function and potential for ambulation can be predicted by the level where the SB occurs (Llopis et al 1993). Patients with SB often have secondary complications. Among these are leg or low-back pain, hip dislocation, scoliosis, kyphosis, foot deformities, pressure sores and hydrocephalus. Hip, knee, ankle and vertebral alignments can be improved with various types of orthoses including HKAFO’s, KAFO’s or RGO’s. The aim of this wiki, however, is to focus on pediatric DAFO’s as an intervention for SB aperta patients with the focus being on the lumbosacral spinal level. It is important to note that DAFO’s are often used in conjunction with other orthotics for walking or for positioning in a wheelchair.

**How Spina Bifida Can Affect Gait** In a study of 100 pediatric subjects with SB (50 with SB aperta and 50 with SB occulta), it was determined using EMG that the tibialis anterior was the most affected muscle (affected in 68%) followed by the medial gastroc and extensor digitorum brevis for muscle weakness. This tells us that dorsiflexion (tib anterior), plantarflexion (gastroc), and toe off (ext dig brevis) are most affected in ambulation (Petronic et al 2011). A patient with SB has several tell-tale characteristics if you observe them walking. Among these are muscle weakness or paralysis, hypotonicity, a more oblique pelvis position, greater pelvis rotation with excessive hip abduction in stance, excessive knee flexion (lack of PF and knee extension) with greater knee valgus moments and medial to lateral ankle instability. Their gait often has a Trendelenburg appearance (Duffy et al. 1996). Alternatively, some patients experience soleus spasticity, which puts them in more of a plantarflexed position and lends itself to more knee hyperextension.

**Gait Videos** [|**http://www.youtube.com/watch?v=2yxdxUcw1BI**] [] []

**Dynamic AFO’s** AFO’s in general have been found to significantly improve dorsiflexion and plantarflexion, increase plantarflexion moments and reduce crouched gait and excessive knee extension moments in patients with myelomeningocele SB (Thompson 1999). Another study found that in L4, L5 and S1-2 affected patients, AFOs in general improved sagittal plane movements. The AFOs also increased the rotational movement the knee, and reduced the power from the ankle, especially in the S1-2 group. The study speculated that over time, the plantarflexors would lose strength from being in the AFO consistently (Thompson et al. 1999). Benefits: Detriments:
 * Improve DF and PF
 * Improve upright posture
 * Reduce knee extension moments
 * Increased knee rotation (torque)
 * Reduced ankle power
 * Possibility of losing PF strength (long-term)

**Examples** DAFO- [] This type allows movement while providing functional support for a child with hypotonicity.

Sure Steps Foot - [|[[http://www.delatorreop.com/pediatric-devices/body-region:lower-extremity/sure-steps-foot-253/.|http://www.delatorreop.com/pediatric-devices/body-region:lower-extremity/sure-steps-foot-253/]]]. This one is specific to a toddler population. The child may be pulling up or cruising. It offers stability and alignment at the ankle.

Ultraflex AFO CM & SMO inserts - [] (see page 5 for soleus spasticity)

This DAFO helps lengthen the soleus which allows for dorsiflexion and knee flexion in ambulation. It is appropriate for patients with less than 15 degrees PROM of the soleus muscle.

**When is an AFO indicated? **  According to Bernie Veldman, certified pediatric orthotist, the question in pediatrics is not “to brace or not to brace”, but “when and how” for pathologies that require attention. Here are some **common misconceptions** he has witnessed:
 * // Hypotonia is essentially inherited flat feet // . The problem is more complex. Hypermobility in the foot and ankle can cause pronation, which in turn, leads to a forward body weight position, internal rotation of the tibia and femur, and a valgus force at the knee. The real issue here is that when this occurs in early walking stages (developmental), it can become permanent.
 * // Low muscle tone is the equivalent of muscle weakness // . Bernie says, “Muscles with low tone can become very strong at their excessive length”. So essentially low muscle tone is not muscle weakness. Muscles can work to your advantage in certain positions.

To know “when” to brace is complicated. One example of the complexity of bracing: In the case of a hypotonic foot, consideration is given to bracing the foot and risk losing intrinsic muscle strength that should develop naturally with age or to dismiss bracing and allow the possibility of either natural correction or the formation of gait deviations. Hopefully, we have given you a little more insight as to “how” to brace children with the common aforementioned pathologies. A decision to brace (or not) ultimately lies with the child & parent(s), caregivers, orthotist and physical therapist. An interdisciplinary approach will probably offer the best outcome for the child. (Veldman) A.D.A.M. (2012). Cerebral Palsy. U.S. National Library of Medicine: PubMed Health. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001734/
 * References **

Auckland Bioengeneering Istitute. (2009). Gait kinematics cerebral palsy. Retrieved from http://www.youtube.com/watch?v=-MMtyzeYVmM

Brayden, MD, Robert. "Muscular Dystrophy." Children's Physician Network, 29 Oct. 2009. Web. 24 Mar. 2012. [].

Cascade DAFO, Inc. (2012). Excessive plantarflexion/toe walking. Cascade. Retrieved from [] Cascade (2012). DAFO Guide to Brace Selection. Retrieved from: []. Cascade Dafo Inc. (2012). Cascade Library - Cascade Dafo. Retrieved March 20, 2012, from [] Cimolin, V., Galli, M., Grugni, G., Vismara, L., Albertini, G., Rigoldi, C., & Capodaglio, P. (2010). Gait patterns in Prader-Willi and Down syndrome patients. //Journal of neuroengineering and rehabilitation//, //7//(1), 28. doi:10.1186/1743-0003-7-28

Clark, Alisa. "Muscular Dystrophy." //Kids Health//. The Nemours Foundation, July 2010. Web. 24 Mar. 2012. []

D'Angeloa, Maria, Matteo Bert, Luigi Piccinini, Marianna Romei, Michela Guglieri, Sara Bonato, et al. "Gait Pattern in Duchenne Muscular Dystrophy." //Gait & Posture// 29(2009): 36-41. Print.

Down syndrome. (2011). A.D.A.M. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001992/ "Duchenne Muscular Dystrophy-Peds." //Johns Hopkins Medicine//. Johns Hopkins University, n.d. Web. 24 Mar. 2012. [].

Duffy, C.M., Hill, A.E, Cosgrove, A.P., Corry, I.S, Mollan, R.A., & Graham, H.K. (1996). Three-Dimensional Gait Analysis in Spina Bifida. [Abstract]. Journal of Pediatric Orthopaedics 16 (6): 786-91.

Figueiredo, E. M., Ferreira, G. B., Maia Moreira, R. C., Kirkwood, R. N., & Fetters, L. (2008). Efficacy of ankle-foot orthoses on gait of children with cerebral palsy: systematic review of literature. Pediatric physical therapy : the official publication of the Section on Pediatrics of the American Physical Therapy Association, 20(3), 207-23. doi:10.1097/PEP.0b013e318181fb34

Galli, M., Rigoldi, C., Brunner, R., Virji-Babul, N., & Giorgio, A. (2008). Joint stiffness and gait pattern evaluation in children with Down syndrome. //Gait & posture//, //28//(Down syndrome, 2011), 502-6. doi:10.1016/j.gaitpost.2008.03.001

Gould, B. & Dyer, Ruthanna. (2011). Pathophysiology for the Health Professions (4th Ed). St. Louis, Missouri: Saunders Elsevier.

Hayek, S., Hemo, Y., Chamis, S., Bat, R., Segev, E., Wientroub, S., & Yzhar, Z. (2007). The effect of community-prescribed ankle-foot orthoses on gait parameters in children with spastic cerebral palsy. Journal of children’s orthopaedics, 1(6), 325-32. Springer. doi:10.1007/s11832-007-0055-z

Llopis, I.D., Munoz, M.B., Agullo, E.M., Martinez, A.L., Aymerich, V.G., & Forner Valero, JV. (1993). Ambulation in patients with myelomeningocele: a study of 1500 patients. International Medical Society of Paraplegia 31:28-32. Retrieved from: **[].** Martin, K. (2004). Effects of supramalleolar orthoses on postural stability in children with Down syndrome. //Developmental medicine and child neurology//, //46//(6), 406-11. Retrieved from []

"Muscular Dystrophies: Duchenne and Becker." //Muscular Dystrophy Austrailia//. Muscular Dystrophy Limited, 2012. Web. 24 Mar. 2012. [].

Petronic, I., Nikolic, D., Cironic, D., Cvjeticanin, S., Knezevic, T., Raicevic, M. … Golubovic, Z (2011). Distribution of affected muscles and degree of neurogenic lesion in patients with spina bifida. //Arch Med Sci 7 (6), 1049-1054. Doi: 10.5114/AOMS.2011.6619.// Selby-Silverstein, L., Hillstrom, H. J., & Palisano, R. J. (2001). The effect of foot orthoses on standing foot posture and gait of young children with Down syndrome. //NeuroRehabilitation//, //16//(3), 183-93. Retrieved from []

Smith, David//.// (2012, February 13). Ankle Foot Orthosis Braces for Spina Bifida Affected Children. //Innovative Articles for Readers//. Retrieved from: [].

SureStep. (2012). Clinician’s Corner. Retrieved from: http://www.surestep.net/clinicians_corner.php.

SureStep. (2012). SureStep products. SureStep. Retrieved from []

Thompson, J.D., Ounpuu, S.M., Davis, R.B., & DeLuca, P.A. (1999). The effects of ankle-foot-orthoses on the ankle and knee in persons with myelomeningocele: an evaluation using three-dimensional gait analysis. [Abstract]. Journal of Pediatric Orthopaedics 19 (1): 27-33.

TheMomtogirls. (2011). Gait analysis: CP spastic diplegia part 2. Retrieved from []

Ultraflex. Managing Challenging Neurological Presentations: Therapeutic Bracing with Precise Dynamic Stimulus and Proper Posturing. Retrieved from: [].

Van den Noort, J. Application of inertial sensing in clinical motor function assessment. VUmc. retrieved from: [].

Veldman, Bernie. Fancy Foot Work: Hypotonia: To Brace or Not to Brace? An Orthotist’s view. //Therapy Talk//. Retrieved from: http://www.surestep.net/media/pdf/Article%20To%20brace%20or%20Not.pdf Venkataramana, N.K. (2011) Spinal Dysraphism. //Journal of Pediatric Neuroscience 6:S31-S40//. Retrieved from: **http://www.ncbi.nlm.nih.gov.proxy.kumc.edu:2048/pmc/articles/PMC3208922/?tool=pubmed.** Winders, P. C. (2001). The goal and opportunity of physical therapy for children with Down syndrome. //Down Syndrome Quarterly//, //6//(2), 1-5. Retrieved from []