Splint: The efficacy of orthotic management in rest to prevent equinus in children with cerebral palsy, a randomised controlled trial

Department of Rehabilitation Medicine and the EGMO+ Institute for Health and Care Research, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
BMC Pediatrics (Impact Factor: 1.93). 03/2012; 12(1):38. DOI: 10.1186/1471-2431-12-38
Source: PubMed


Range of motion deficits of the lower extremity occur in about the half of the children with spastic cerebral palsy (CP). Over time, these impairments can cause joint deformities and deviations in the children's gait pattern, leading to limitations in moblity. Preventing a loss of range of motion is important in order to reduce secondary activity limitations and joint deformities. Sustained muscle stretch, imposed by orthotic management in rest, might be an effective method of preventing a decrease in range of motion. However, no controlled study has been performed.
A single blind randomised controlled trial will be performed in 66 children with spastic CP, divided over three groups with each 22 participants. Two groups will be treated for 1 year with orthoses to prevent a decrease in range of motion in the ankle (either with static or dynamic knee-ankle-foot-orthoses) and a third group will be included as a control group and will receive usual care (physical therapy, manual stretching). Measurements will be performed at baseline and at 3, 6, 9 and 12 months after treatment allocation. The primary outcome measure will be ankle dorsiflexion at full knee extension, measured with a custom designed hand held dynamometer. Secondary outcome measures will be i) ankle and knee flexion during gait and ii) gross motor function. Furthermore, to gain more insight in the working mechanism of the orthotic management in rest, morphological parameters like achilles tendon length, muscle belly length, muscle fascicle length, muscle physiological cross sectional area length and fascicle pennation angle will be measured in a subgroup of 18 participants using a 3D imaging technique.
This randomised controlled trial will provide more insight into the efficacy of orthotic management in rest and the working mechanisms behind this treatment. The results of this study could lead to improved treatments.
Nederlands Trial Register NTR2091.

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    ABSTRACT: Objective: To examine whether using a knee-ankle-foot orthosis helps maintain ankle-foot dorsiflexion range of motion over time. Design: A multicentre randomized controlled trial. Setting: Two hospitals and one rehabilitation centre in the Netherlands and the USA. Subjects: Children (4-16 years old) with spastic cerebral palsy who were able to walk. Intervention: Use of a knee-ankle-foot orthosis, equipped with an Ultraflex (R) ankle power unit, for at least 6 hours every other night for one year. Main measures: Primary outcome measure: ankle-foot dorsiflexion range of motion. Secondary outcome measures: ankle-foot and knee angle in gait and gross motor function. Wearing time was also measured. Measurements were taken at baseline and at 3, 6, 9 and 12 months. Results: 28 children (experimental group: n=15, control group: n=13) participated in the study. 11 participants (experimental: n=4, control: n=7) did not complete all five measurements, as they needed additional treatment. No significant difference was found in the decrease of ankle-foot dorsiflexion range of motion between the experimental and control groups (difference: -1.05 degrees, 95% confidence interval: -4.71 degrees-2.61 degrees). In addition, secondary outcome measures did not show differences between groups. Despite good motivation, knee-ankle-foot orthosis wearing time was limited to a mean +/- SD of 3.2 +/- 1.9 hours per prescribed night due to discomfort. Conclusions: Knee-ankle-foot orthosis with dynamic ankle and fixed knee are poorly tolerated and are not beneficial in preventing a reduction in ankle-foot dorsiflexion range of motion in children with spastic cerebral palsy, at least with limited use.
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    ABSTRACT: Purpose: To determine the effects of decreased ankle-foot dorsiflexion (A-Fdf) range of motion (ROM) on gait kinematics in children with spastic cerebral palsy (SCP). Methods: All participants were children with spastic cerebral palsy (n=10) who walked with knee flexion in midstance. Data were collected over 2-5 sessions, at 3-monthly intervals. A-Fdf ROM was quantified using a custom-designed hand-held ankle dynamometer that exerted 4Nm at the ankle. Ankle-foot and knee angles during gait were quantified on sagittal video recordings. Linear regression (cross-sectional analysis) and General Estimation Equation analysis (longitudinal analysis) were performed to assess relationships between (change in) A-Fdf ROM and (change in) ankle-foot and knee angle during gait. Results: Cross-sectional analysis showed a positive relationship between A-Fdf ROM and both ankle-foot angle in midstance and terminal swing. Longitudinal analysis showed a positive relationship between individual decreases in A-Fdf ROM and increases of knee flexion during gait (lowest knee angle in terminal stance and angle in terminal swing). Conclusion: For this subgroup of SCP children, our results indicate that while changes in ankle angles during gait are unrelated to changes in A-Fdf ROM, changes in knee angles are related to changes in A-Fdf ROM. Copyright © 2014. Published by Elsevier Ltd.
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