Is functional electrical stimulation an alternative for orthotics in patients with cerebral palsy? A literature review

Background

Functional electrical stimulation (FES) is a well-known intervention used during walking to improve walking abilities and correct gait deviations by facilitating the proper muscle group at the appropriate timing in the gait cycle. Our aim was to study the types of surface FES currently used in a cerebral palsy (CP) population and examine the evidence of its ability to improve gait deviations, functional ability and therapeutic effects.

股骨远端截骨和髌腱止点远端移位联合手术治疗儿童脑瘫屈膝步态的近期效果评价

目的 评价股骨远端截骨和髌腱止点远端移位联合手术治疗儿童痉挛性脑瘫屈膝步态的近期效果.方法 2009年4月至2012年7月对存在屈膝步态、膝关节固定屈曲畸形10°～30°的痉挛性脑瘫儿童行股骨远端截骨和髌腱止点远端移位联合手术.16例(26侧下肢)纳入研究,其中男11例,女5例,年龄7.5～11.6岁,平均8.9岁.术后高分子绷带固定6周,拆除石膏后功能锻炼,夜间长腿管型支具固定维持矫形.记录手术前后的膝关节固定屈曲畸形角度、腘角、膝关节活动范围、屈膝步态改善情况、膝关节疼痛视觉模拟评分(VAS)评分、股四头肌肌力、腘绳肌肌力、小腿三头肌肌力、侧位膝关节X线片Insall-salvati指数和Wren改良的屈膝步态的医师视觉评分,并进行统计学分析.结果 GMFCS分级为Ⅱ级9例,Ⅲ级7例,无GMFCS分级Ⅰ、Ⅳ、Ⅴ级病例.均行股骨远端截骨和髌腱止点远端移位联合手术.6侧下肢同时行髂腰肌松解术.10侧下肢同时行跟腱延长术.病例随访48～65个月,平均54个月.治疗后所有病例屈膝步态均明显改善或消失.患儿膝关节疼痛VAS评分较术前降低(P＜0.05).膝关节屈曲畸形角度及腘角明显减小(P＜0.01),膝关节屈伸活动范围明显增大(P＜0.01).股四头肌肌力显著增加(P＜0.05).腘绳肌肌力、小腿三头肌肌力无显著变化.侧位膝关节X线片Insall-salvati指数明显减小,髌骨高位得到纠正.2例(2侧下肢,7.7％)出现一过性坐骨神经损伤症状,经更换高分子绷带,增大膝关节屈曲至20°左右,并予营养神经等对症处理后症状消失.2例(3侧下肢,11.5％)出现切口感染,经换药处理后愈合.3例(3侧下肢,11.5％)出现股骨截骨远端轻度移位,未做特殊处理,截骨端塑型良好.无一例出现过度矫正、膝反屈、压疮等其他并发症.结论 股骨远端截骨和髌腱止点远端移位联合手术治疗儿童脑瘫屈膝步态能有效改善步态,纠正膝关节屈曲畸形和髌骨高位,增加股四头肌肌力,减轻膝关节疼痛,近期效果良好.     

脑瘫患儿内侧腘绳肌延长术后步态分析

目的利用计算机辅助的定量步态分析技术,评价内侧腘绳肌延长术对双侧痉挛性脑瘫步态的影响。方法将双侧痉挛性脑瘫患儿分为两组,一组为髂腰肌组,采取内侧腘绳肌延长,股直肌远端转位加髂腰肌延长术。另一组为非髂腰肌组,采取内侧腘绳肌延长,股直肌远端转位术。利用计算机辅助的定量步态分析技术．对两组患儿术前和术后运动学、动力学数据进行比较分析。结果髂腰肌组术后骨盆前倾角度明显增大,髋关节屈曲度增加,并出现膝反屈倾向。结论①髂腰肌组术后出现“腘绳肌功能不全”模型,即骨盆过度前倾、髋关节屈怕度增加和膝反屈倾向。②腘窝角的测量结果不能作为腘绳肌延长术的唯一指征。③股直肌远端转位术可改善蹲伏步态患儿膝关节在摆动期的增大屈膝角度,使足有较大的自由活动空间。④计算机辅助的定量步态分析可对复杂的病理步态进行全面、客观、动态的描述。     

Effects of Strength Training Aided by Electrical Stimulation on Wrist Muscle Characteristics and Hand Function of Children with Hemiplegic Cerebral Palsy

Nine children with spastic hemiplegic cerebral palsy underwent 24 sessions of wrist muscles strengthening in the extended wrist range aided by electrostimulation. Isometric strength of flexors and extensors was registered in three wrist positions (30° of flexion, neutral, and 30° of extension) to infer on angle–torque curves. Passive stiffness of wrist flexors and wrist flexion angle during manual tasks and hand function were also documented. Significant strength gains were observed at 30° of wrist extension for flexors (p = 0.029) and extensors (p = 0.024). No gains were observed at 30° of flexion. The difference in extensor strength between the three test positions changed after intervention (p < 0.034), suggesting a shift in the angle–torque curve. No changes were observed in passive stiffness (p = 0.506), wrist angle (p < 0.586), or hand function (p = 0.525). Strength training in specific joint ranges may alter angle–torque relationships. For functional gains to be observed, however, a more aggressive intervention and contextualized task training would probably be needed.     

The effect of individually defined physiotherapy in children with cerebral palsy (CP)

AimThis prospective double blind intervention study aims to evaluate the effectiveness of an individually defined physiotherapy program on the function and gait pattern of 16 children with diplegia (age 3–12 year, GMFCS I–II).MethodA 6 weeks general training program was followed by a specific training program based on individual goals determined by the results of 3D gait analyses, GMFM-88 and a clinical evaluation. Goal attainment scores were used for the evaluation of the achievement of individual goals.ResultsAfter the general training program, 6.7% of the children achieved the treatment goals, 33.3% stayed at the same level and 60% worsened and this in comparison to 40, 33.3 and 26.6% of the children respectively after the individually defined training program. The improvement for walking, running and jumping of the GMFM-88 was significantly more pronounced after the individually defined (p < 0.05), compared to the general training program. Whereas ankle dorsiflexion, spasticity of the hamstrings (p < 0.01), selectivity of hip abductors, knee extensors and ankle dorsiflexors significantly improved over the complete period of study (p < 0.01), hip extension, step length, stride length, ankle power generation and all hip parameters changed specifically after the individually defined training program (p < 0.01).ConclusionA quantified effect is manifest with the application of an individually defined training program over a six weeks period.     

Congenital genu recurvatum. Presentation of 2 cases

Two cases of genu recurvatum congenitum are reported having been brought to the authors' attention within a short space of one another. In both cases this malformation, which is not very common, was associated with other anomalies. The malformation is characterised by an exaggerated hyperextension of the knee, sometimes to such an extent that the angle of the foreward bend is less than 100 degrees, whereas flexion is almost impossible on account of the strong retraction of the femoral quadriceps. The first of the two cases was resolved relatively easily following treatment with a plaster cast and subsequent physiotherapy. The second case requires longer and more complex treatment, also involving surgery, given the complete loss of joint contacts and the presence of club feet.     

Effect of joint injections in children with juvenile idiopathic arthritis: evaluation by 3D-gait analysis

AIM: To investigate how gait patterns change after intra-articular corticosteroid injections (ICIs) in the lower extremities. METHODS: Eighteen children, aged 5-16 y, with juvenile idiopathic arthritis (JIA) and lower extremity involvement participated in the study. Sixty-four joints in the lower extremities were treated with ICIs. The Visual Analogue Scale (VAS, 0-100 mm) was used to assess pain. A 3D motion analysis system and two force plates were used to measure gait parameters, kinematics and kinetics. The first gait analysis was performed before treatment with ICIs, and a second one was done 8-17 d after treatment. RESULTS: The participants' average rating of pain decreased from 26 mm on the VAS before ICI to 11 mm (p = 0.001) after treatment. The self-chosen walking velocity was significantly faster (p = 0.02) after treatment. The range of knee and ankle joint angles during gait increased significantly (p = 0.03 and 0.04) after treatment. At loading response, the hip extension moment increased (p = 0.01) as did knee flexion moment, and plantar flexion moment at pre-swing increased significantly (p = 0.02 and 0.002) after treatment. The ankle also generated more power (p = 0.005) after treatment. CONCLUSION: The study shows positive effects of treatment with ICIs in the lower extremities--especially regarding pain, walking velocity and joint moments. The data indicate that ICI treatment influences the gait pattern also in joints that have not been injected.     

Gait abnormalities in people with Dravet syndrome: A cross-sectional multi-center study

ObjectiveTo quantify gait abnormalities in people with Dravet syndrome (DS).MethodsIndividuals with a confirmed diagnosis of DS were enrolled, and stratified according to knee flexion at initial contact (IC) and range of motion (ROM) during stance (atypical crouch: knee flexion >20° at IC and knee ROM >15° during stance; straight: knee flexion <20° at IC). A 1D ANOVA (α = 0.05) was used to test statistical differences among the joint kinematics and spatio–temporal parameters of the cohort and an age-matched control group. Clinical (neurological and orthopaedic evaluation) and anamnestic data (seizure type, drugs, genetic mutation) were collected; distribution between the two gait phenotypes was assessed with the Fisher exact test and, for mutation, with the chi-squared test (p < 0.05). Linear regression between maximum knee flexion and normalised walking speed was calculated.ResultsSeventy-one subjects were enrolled and evaluated with instrumented gait analysis. Fifty-two were included in final analysis (mean age 13.8 ± 7.3; M 26). Two gait patterns were detected: an atypical crouch gait (34.6%) with increased ankle, knee and hip flexion during stance, and reduced walking speed and stride length not associated with muscle-tendon retractions; and a pattern resembling those of healthy age-matched controls, but still showing reduced walking speed and stride length. No differences in clinical or anamnestic data emerged between the two groups.SignificanceObjectively quantified gait in DS shows two gait patterns with no clear-cut relation to clinical data. Kinematics abnormalities may be related to stabilization issues. These findings may guide rehabilitative and preventive measures.     

MRI assessment of tenosynovitis in children with juvenile idiopathic arthritis: inter- and intra-observer variability

Background

There is sparse knowledge about grading tenosynovitis using MRI.

Objective

The purpose of this study was to assess the reliability of a tenosynovitis MRI scoring system in juvenile idiopathic arthritis.

Materials and methods

Children with juvenile idiopathic arthritis and wrist involvement were enrolled in two paediatric centres, from October 2006 to January 2010. The extensor (compartments II, IV and VI) and flexor tendons were assessed for the presence of tenosynovitis on T1-weighted postcontrast fat-saturated MR images and were scored from 0 (normal) to 2 (moderate to severe) by two observers independently. Intra- and interobserver agreement was assessed.

Results

Ninety children (age range: 5–18.5 years) were included, of whom 34 had tenosynovitis involving extensors and 28 had tenosynovitis involving flexors. A total of 360 tendon areas were analysed, of which 114 had tenosynovitis (86/270 extensors and 28/90 flexors). Intra-reader 1 agreement was excellent for the extensors (k = 0.82–0.91) and for the flexors (k = 0.85); intra-reader 2 agreement was moderate to good for the extensors (k = 0.51–0.72) and good for the flexors (k = 0.64). Inter-reader agreement was good for the extensors (k = 0.69–0.73) and moderate for the flexors (k = 0.49).

Conclusion

The proposed MRI scoring system for the assessment of wrist tenosynovitis in juvenile idiopathic arthritis appears feasible with an observer agreement sufficient for clinical use.     

Congenital hyperextension of the knees in twins

Bilateral congenital hyperextension of the knees occurring in dizygotic twins is reported. Twin A had the mild form of the disease, genu recurvatum, while twin B had a more severe form of the disease, congenital subluxation. Hyperextension of the knee may occur as a sporadic abnormality, in conjunction with multiple dislocations or as a feature of a syndrome. Early detection and diagnosis are important, especially in the more severe forms of the condition, subluxation and dislocation, which require aggressive immediate intervention to prevent long-term sequelae. Conservative treatment consisting of manipulations and immobilization usually will correct the mild forms of the condition if instituted soon after birth. Prognosis is less favorable with delayed treatment, in the presence of other congenital anomalies, and with genetic syndromes.     

Distal femoral extension and shortening osteotomy as a part of multilevel surgery in children with cerebral palsy

Background:There are several reports describing an increase in anterior pelvic tilt after hamstring lengthening in children with cerebral palsy (CP).Distal femoral extension and shortening osteotomy (DFESO) is an alternative treatment for correction of flexed knee gait,but investigations analyzing outcome and influence on adjacent joint are few in the literature.The purpose of this study was to analyze the influence of DFESO on knee and pelvis in children with CP.Furthermore,it was of interest if an additional patellar tendon advancement (PA) influences outcome.Methods:In this retrospective study,31 limbs of 22 children (GMFCS Ⅰ-Ⅲ;mean age:12.1±3.1 years),who received DFESO were included and kinematic parameters (knee,pelvis) measured by 3-D-gait analysis were compared before and at least 1 year after surgery (mean follow-up period:15.6 months).Results:After surgery,during stance phase minimum knee flexion improved significantly by 20.5° (P＜0.001) and mean anterior pelvic tilt increased by 4.0 degrees (P=0.045).In 16 limbs,the postoperative increase in maximum anterior pelvic tilt was more than 5°.Limbs who received an additional PA showed the biggest increase in anterior pelvic tilt.Conclusions:DFESO is an effective method for correction of flexed knee gait in children with CP.Furthermore,the results of this study indicate that DFESO may lead to an increase in anterior pelvic tilt,which may lead to a recurrence of flexed knee gait.In this context,PA seemed to aggravate the effect on the pelvis.     

The association between adiposity and the response to resistance training among pre- and early-pubertal boys

Resistance training has been shown to be effective in enhancing muscle strength among prepubertal and adolescent boys. Lately, it has been recommended for obese children. We hypothesized that resistance training will be similarly effective among boys of different adiposity. Thirty boys, aged 9.2 +/- 0.3 years, participated in progressive resistance training twice weekly during the first and second school years and thrice weekly during the third year. Training sessions included 1-4 sets of 3-6 exercises, with 5-30 repetitions/set. The mean load was 50-60% of 1 repetition maximum. Subjects were divided into responders (R--upper tertile) and non-responders (NR--lower tertile), according to the three-year improvement in muscle strength, as assessed by means of changes in concentric strength of knee flexors and extensors. Differences between groups were observed at baseline (p <0.05) in all variables reflecting adiposity (mean +/- SD): % body fat (14.1 +/- 2.6 vs 23.5 +/- 7.5% for R and NR, respectively), sum of four skinfolds (25.4 +/- 4.7 vs 47.8 +/- 21.6 mm for R and NR, respectively), BMI (15.5 +/- 1.1 vs 18.6 +/- 2.6 kg x m(-2) for R and NR, respectively). Additionally, the changes in adiposity were inversely related to the training effect (r = -0.60 to -0.34). No differences were observed in initial height and maturation between R and NR groups and there was no difference in linear growth and physical maturation with time between groups. These data suggest that resistance-training loads which may be appropriate to increase strength of knee flexors and extensors in normal-weight children may be insufficient to do so in overweight children. More research is required to elucidate the efficacy of resistance training among overweight children.     

Selective dorsal rhizotomy for children with cerebral palsy: the Oswestry experience.

BACKGROUND: Although three randomised control trials have shown that selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy, a meta-analysis of the results demonstrated that the procedure conferred only small functional benefit on the patient. AIM: To determine whether applying strict criteria for patient selection as practised in Oswestry leads to improved outcomes, using gait analysis as an outcome measure. METHODS: Ambulant children with cerebral palsy were selected for SDR using very strict clinical criteria. Instrumented gait analysis was used as the main outcome measure. RESULTS: Of 53 children referred for the procedure, only 19 (35%) fulfilled our strict criteria for selection. These children underwent surgery and when pre- and post-SDR data were compared, they showed improvement in cosmesis of gait, clinical examination and temporal, kinetic and kinematic parameters of gait. After SDR the children walked, on average, 0.15 m/s faster, with a step length improvement of 0.11 m. Changes were seen at hip, knee and ankle, with those at the knee being most marked. A 0.3 grade improvement in knee extensor power on clinical examination led to a 13 degrees improvement in stance phase knee extension. Knees also became less stiff, with an 82 degrees /s improvement in the rate of flexion into swing phase. A functional tool (the GMFCS) applied retrospectively also confirmed post-operative improvement, with 15 of the 19 children improving by at least one level. CONCLUSION: Application of strict selection criteria when considering children for SDR leads to encouraging results as demonstrated by gait analysis and other measures.     

Botulinumtoxin A treatment in toddlers with cerebral palsy

Aims: In this study the aim was to evaluate the effect of botulinum toxin A (BoNT‐A) treatment on muscle tone, contracture development and gait pattern in young children with cerebral palsy (CP). Method: Fifteen children with spastic CP (mean age = 16 months) were included in a randomized control study. All received a daily stretching programme and children in the BoNT‐A group additionally received two injections, 6 months apart in the gastrocnemius muscle. Outcomes were assessed at baseline, and after 1 and 3.5 years. A 3D gait‐analysis was performed at 5 years of age. Results: Plantarflexor muscle tone in the BoNT‐A group was significantly reduced after 3.5 years, while the muscle tone at the ankle and knee in the control group remained unchanged. The change‐score in knee‐flexion muscle tone between the groups was significantly different after 3.5 years. The knee joint ROM was significantly increased at 1 year in the BoNT‐A group but reduced at the knee and ankle joints in the control group after 3.5 years. No group differences were found for gait analysis, GMFM‐66 or PEDI. Conclusion: Early treatment of BoNT‐A in children with spastic CP may decrease muscle tone and decelerate contracture development after 3.5 years. The effect on gait development remains inconclusive.     

Japanese clinical guidelines for juvenile orthostatic dysregulation version 1

This clinical practice guideline provides recommendations for the assessment, diagnosis and treatment of school-aged children and juveniles with orthostatic dysregulation (OD), usually named orthostatic intolerance in USA and Europe. This guideline is intended for use by primary care clinicians working in primary care settings. The guideline contains the following recommendations for diagnosis of OD: (i) initial evaluation composed of including and excluding criteria, the assessment of no evidence of other disease including cardiac disease and so on; (ii) a new orthostatic test to determine four different subsets: instantaneous orthostatic hypotension, postural tachycardia syndrome, neurally mediated syncope and delayed orthostatic hypotension; (iii) evaluation of severity; and (iv) judgment of psychosocial background with the use of rating scales. The guideline also contains the following recommendations for treatment of OD on the basis of the result of an orthostatic test in addition to psychosocial assessment: (i) guidance and education for parents and children; (ii) non-pharmacological treatments; (iii) contact with school personnel; (iv) use of adrenoceptor stimulants and other medications; (v) strategies of psychosocial intervention; and (vi) psychotherapy. This clinical practice guideline is not intended as a sole source of guidance in the evaluation of children with OD. Rather, it is designed to assist primary care clinicians by providing a framework for decision making of diagnosis and treatments.     

Gait deviations in patients with dravet syndrome: A systematic review

BackgroundDravet Syndrome is a rare developmental and epileptic encephalopathy characterised by epileptic seizures, cognitive impairment and motor disorders. Gait is markedly impaired and could benefit from targeted intervention to improve quality of life for patient and caregivers.ObjectiveTo establish the state of the art regarding gait deviations in patients with Dravet Syndrome.MethodsA systematic search was performed in Pubmed, Web of Science, Science Direct and Embase. Studies that assessed gait deviations in patients diagnosed with Dravet Syndrome using clinical observation, video gait analysis or three dimensional (3D) gait analysis and reported gait characteristics, spatiotemporal or kinematic outcomes were included. Screening, quality assessment and data extraction were performed by independent reviewers.ResultsOut of a total of 478 citations, nine articles were included. The total study population had an age range from 2.5 to 47 years. Three studies used clinical observation, three studies video analysis and three studies 3D gait analysis. Crouch gait was observed in about half of the population next to a variety of other gait deviations such as parkinsonian and cerebellar gait. Other findings included abnormalities in spatiotemporal parameters and kinematics, passive knee extension deficits, skeletal malalignment and neurological signs.ConclusionsA variety of gait characteristics was observed with crouch gait being the most reported gait pattern. Inconsistency in methods and findings from clinical and instrumented evaluation impede thorough understanding of the causal mechanism and evolution behind these deviations.PROSPERO registration numberCRD42017070370.     

Selective dorsal rhizotomy for children with cerebral palsy: the Oswestry experience

Background

Although three randomised control trials have shown that selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy, a meta‐analysis of the results demonstrated that the procedure conferred only small functional benefit on the patient.

Aim

To determine whether applying strict criteria for patient selection as practised in Oswestry leads to improved outcomes, using gait analysis as an outcome measure.

Methods

Ambulant children with cerebral palsy were selected for SDR using very strict clinical criteria. Instrumented gait analysis was used as the main outcome measure.

Results

Of 53 children referred for the procedure, only 19 (35%) fulfilled our strict criteria for selection. These children underwent surgery and when pre‐ and post‐SDR data were compared, they showed improvement in cosmesis of gait, clinical examination and temporal, kinetic and kinematic parameters of gait. After SDR the children walked, on average, 0.15 m/s faster, with a step length improvement of 0.11 m. Changes were seen at hip, knee and ankle, with those at the knee being most marked. A 0.3 grade improvement in knee extensor power on clinical examination led to a 13° improvement in stance phase knee extension. Knees also became less stiff, with an 82°/s improvement in the rate of flexion into swing phase. A functional tool (the GMFCS) applied retrospectively also confirmed post‐operative improvement, with 15 of the 19 children improving by at least one level.

Conclusion

Application of strict selection criteria when considering children for SDR leads to encouraging results as demonstrated by gait analysis and other measures.     

Multidimensional outcome measure of selective dorsal rhizotomy in spastic cerebral palsy

BackgroundOne of the treatment option to reduce spasticity in cerebral palsy children is selective dorsal rhizotomy. Several studies have demonstrated short and long term improvements in gait and other activities after rhizotomy but this surgery still remains a controversial procedure and patient outcome indicators measures are not uniform.AimsTo describe our assessment and outcome evaluation protocol and to verify by this protocol short term results of rhizotomy.MethodsWe recruited 9 cerebral palsy children (mean age 7.9 years ± 3.2) affected by mild to moderate spastic diplegia and operated by rhizotomy. Patients were studied preoperatively and at 12 months after surgery by the following clinical and instrumental measures correlated to the International Classification of Functioning: modified Ashworth Scale, passive Range of Motion, Medical Research Council Scale, Selective Motor Control Scale, 3D-motion analysis and energy cost of locomotion measurements (indicators of “body functions”); Gross Motor Functional Measure and Motor Functional Independence Measure (indicators of “activities and participation”).ResultsOur data showed, after rhizotomy, reduction of spasticity specially in plantarflexors muscles (p < 0.01), increase of strength of knee flexors/extensors and foot plantar/dorsiflexion muscles (p < 0.01), improvement of selective motor control (p < 0.05), more similar spatio-temporal parameters of gait analysis to healthy subjects, reduced equinus foot and knees hyperflexion as energy cost.ConclusionThe complementary use of multiple indicators may improve the evaluation of the results of dorsal rhizotomy. A beneficial outcome measured by these indicators has been found in our spastic diplegic children one year after rhizotomy.     

Therapie spastischer Gangstörungen im Wachstum

Spastic motor disorders usually present with weakness which is possibly more important than spasticity. The indications for measures causing weakening must therefore be evaluated very carefully. The clinical assessment of muscle function only poorly correlates with functional problems, hence function should be measured if possible. Stability of the stance leg is essential for walking which is provided by powerful plantar flexors and a stable foot as a lever arm. Equinus deformity shortens this lever arm as well as foot deformities. For this purpose the feet need to be supported and well controlled. Both tasks are provided by orthotic devices. Functional orthotics must be constructed optimally considering biomechanics as otherwise small deviations can cause more damage than benefits. Once a patient is almost skeletally mature, surgery can replace orthotics in many cases. The biomechanical aim is always 90° foot against shank axis, 0° knee extension and 0° hip extension. If toe walking persists after positioning the foot correctly, weakening the knee flexors (hamstrings and gastrocnemii muscles) may be an option.     

Ocular medicines in children: the regulatory situation related to clinical research

Background

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.

Methods

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.

Discussion

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.

Trial Registration Number

Nederlands Trial Register NTR2091