The influence of ankle-foot orthoses on gait pathology in children with cerebral palsy: A retrospective study.

BACKGROUND: Ankle-foot orthoses (AFOs) are frequently prescribed in children with cerebral palsy (CP) to improve their gait. Due to the heterogeneous nature of CP and contradictions among previous studies, it is important to evaluate the AFO-specific effects, as well as explore their effects on different gait patterns. RESEARCH QUESTIONS: a) What are the prevalence and specific features of AFOs in children with CP? b) How do AFOs affect gait pathology in children with CP? c) What are the pattern-specific effects of AFOs in children with CP? METHODS: A group of 170 patients with CP underwent a three-dimensional gait analysis with and without AFOs (either carbon fiber, rigid, flexible or hinged). The gait profile score, the gait variable scores of the hip, knee and ankle joints, non-dimensional step length and walking speed were used as outcome measures. The AFO-specific effects on the kinematic and kinetic waveforms were investigated using statistical non-parametric mapping (SnPM). Effects were considered relevant when the minimal clinically important difference (MCID) or the standard errors of measurement, for the parameters or the waveforms respectively, were exceeded. RESULTS: Rigid AFOs were prescribed for more than 80 % of the children. Significant beneficial effects were observed for non-dimensional step length and walking speed. Most changes in gait indices were not considered relevant. The SnPM-analyses on the total group and specific gait patterns revealed that walking with AFOs improved the kinematic and kinetic waveforms. These effects were relevant, and were most obvious for crouch, apparent equinus and the total group. SIGNIFICANCE: The use of AFOs improves gait, whether we inspect a total -and thus heterogeneous- group or focus on specific gait patterns. However, focussing on specific parameters (i.e. general gait indices) does not provide a full picture of the AFO-effects.

Effectiveness of robotic exoskeletons for improving gait in children with cerebral palsy: A systematic review.

BACKGROUND: Robotic exoskeletons have been developed to assist locomotion and address gait abnormalities in children with cerebral palsy (CP). These wearable assistive devices provide powered assistance to the lower-extremity joints, as well as support and stability. RESEARCH QUESTION: Does exoskeleton-assisted walking improve gait in children with CP? METHODS: The PRISMA guidelines were used to conduct this systematic review. Articles were obtained in a search of the following electronic databases: Embase, CINAHL Complete, PubMed, Web of Science and MEDLINE. Studies investigating spatiotemporal, kinematic, kinetic, muscle activity and/or physiological parameters during exoskeleton-assisted walking in children with CP were included. All articles were assessed for methodological quality using an adapted version of the Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group, provided by the National Institutes of Health (NIH). RESULTS: Thirteen studies were included. They involved the use of the following exoskeletons: tethered knee exoskeleton, pediatric knee exoskeleton (P.REX), untethered ankle exoskeleton, WAKE-Up ankle module, WAKE-Up ankle & knee module and unilateral ankle exosuit. Methodological quality varied, with key limitations in sample size and allocated time to adapt to the exoskeleton. There was a consensus that robotic exoskeletons improve gait given careful optimisation of exoskeleton torque and sufficient exoskeleton practice time for each participant. Improvements in gait included reduced metabolic cost of walking, increased walking speed, and increased knee and hip extension during stance. Furthermore, exoskeletons with an actuated ankle module were shown to promote normal ankle rocker function. SIGNIFICANCE: Robotic exoskeletons have the potential to improve the mobility of CP children and may therefore increase community participation and improve quality of life. Future work should involve larger controlled intervention studies utilising robotic exoskeletons to improve gait in children with CP. These studies should ensure sufficient exoskeleton practice time for each participant.