Prescription of Ankle-Foot Orthoses for Children with Cerebral Palsy
Purpose: Ankle foot orthoses (AFOs) are frequently prescribed to address gait impairments for children with cerebral palsy (CP). Successful treatment with AFOs depends on optimal prescription, matching the design of the brace to the individual child’s physical impairments; however, research evidence does not exist to help health care professionals decide on the best AFO design to meet each child’s needs. Therefore, this thesis explored current AFO prescription practices, and aimed to improve evidence to assist clinicians in making prescription decisions for children with CP. Methods and Results: To examine the experiences and perspectives of clinicians on AFO prescription for children with CP, we conducted focus groups and semi-structured interviews with 32 clinicians who were involved with AFO prescription for children with CP in five Canadian rehabilitation facilities. Using Interpretive Description as a framework for analysis, we identified three categories from the data: 1) What is made, 2) How it is used, and 3) Factors that support or challenge outcomes. Throughout the interviews, the theme of prescription as a collaborative, iterative, and individualized process emerged. To explore evaluation and clinical decision-making practices of physical therapists for AFO prescription and follow-up, we invited Canadian physical therapists (PTs) working with children who have CP to complete an online survey. Sixty completed responses were received. Three researchers conducted a conventional content analysis to examine the open-ended responses, and descriptive statistics were used to summarize the closed-ended responses. Three themes were identified: 1) Focus on impairment level measures, 2) Inconsistent practices between PTs, and 3) Lack of confidence/knowledge about casting positions and AFO types. To investigate the effects of individualizing the angle of the ankle in the AFO on walking mechanics and function, gait biomechanics were studied in ten children with CP. Fifteen typically-developing children provided normative data. Using three-dimensional gait analysis, kinematics and kinetics were compared between the child’s usual AFO(s) and AFOs that were fabricated with an ankle angle that was individualized for each child. Net responses to the individualized ankle angle were positive for 60% of limbs, negative for 40%. The greatest benefits were observed at the knee, suggesting that this may be a beneficial approach to orthotic intervention for some children with CP. Conclusions: There is limited understanding of how AFOs are prescribed for children with CP in Canada. This thesis highlights the importance of multidisciplinary collaboration, objective evaluation, and individualized clinical problem-solving to facilitate the evolution of the AFO prescription from a medical directive to an orthotic device that optimally benefits the child. This is the first step toward the development of guidelines to help clinicians improve AFO prescription for children with CP.
cerebral palsy, ankle-foot orthoses, orthotic prescription, gait biomechanics, children, clinical decision-making
Doctor of Philosophy (Ph.D.)