Orthotic Management of Children with Cerebral Palsy

The International Classification of Functioning, Disability and Health (ICF) distinguishes impairments of body structure from activity limitations and participation exclusions. 1 By definition, the impairment known as cerebral palsy (CP) describes damage to the immature brain resulting in problems with balance, coordination, and movement. Understanding the effects of such a complex condition is a constant challenge to developing treatment regimens to improve the health of children with CP. A consensus for describing the primary neurological impairment has been presented by the group for the Surveillance of Cerebral Palsy in Europe (SCPE). 2 The impact of skeletal growth during childhood can compound the primary problem if muscles fail to lengthen in proportion to their adjacent long bones. Therefore, although CP is by definition a static neurological lesion, the phenotype has also been labeled with the secondary impairment of a ‘progressive neuromuscular deformity.’3 Children with CP are often limited in their activities because of primary and secondary impairments. A valid and reliable means of measuring functional limitations in children with CP is now possible using the Gross Motor Function Classification System (GMFCS) for children up to 12 years old. 4 The GMFCS enables clinicians to describe the severity of a child’s functional limitations in one of five levels. Children in Level I are only mildly affected and can achieve most the activities of their age-matched healthy counterparts, with only modest qualitative differences. Conversely, children in Level V are the most limited in their activities and have little ability to control their head and trunk posture to counter the effects of the motor impairment and gravity. Rates of functional limitation in mobility, manual dexterity, speech, and vision, and to a lesser extent hearing and cognition, have been shown to correlate with GMFCS level. 5 TREATMENT GOALS In conjunction with other medical, surgical, and therapeutic interventions, orthoses continue to play an important role in the physical management of children with CP. Orthoses are designed with one of two primary aims: either to affect the body structure or to assist function, although for children with CP, orthoses are frequently designed to achieve both of these aims. The aims of lower limb orthotic management of CP were identified by the consensus conference convened by the International Society of Prosthetics and Orthotics 6: To correct and/or prevent deformity To provide a base of support To facilitate training in skills To improve the efficiency of gait It is clear that the first of these aims fits with interventions designed to affect the body structure, whereas the remainder involve overcoming activity limitations. These aims may similarly be applied to the role that orthotic interventions can play in the management of postural impairments of the trunk and upper limbs. However, some degree of compromise is necessary because orthoses prescribed to prevent or correct deformities can impose additional activity limitations by restricting movement. To Correct and/or Prevent Deformity Mobile joint deformities caused by gravity or unbalanced muscle forces can be corrected passively and the position maintained using orthoses. Fixed deformities caused by relative shortening of muscles and soft tissues and structural deformities of abnormal bone shape cannot be passively corrected and must be accommodated in orthoses. Ensuring that muscles spend more than 6 hours during each 24-hour period in an elongated position may help to prevent or reduce the rate of progressive contractures. 7 However, stretching muscles using active forces for shorter periods may perhaps be more effective than maintaining a static position to increase muscle length and hence the available range of motion at joints. 8 To Provide a Base of Support Stability in any position of lying, sitting, or standing requires consideration of both intrinsic and extrinsic factors. Intrinsic stability involves controlling the position of the center of mass within the body. Extrinsic stability involves maintaining the center of mass within the supporting area. Hip abduction orthoses may improve stability and sitting balance by increasing the size of the support area, either in combination with a spinal orthosis or by encouraging independent control for the position of the center of mass of the trunk. Similarly, standing frames use hip-knee-ankle-foot-orthoses to control body position and wide bases of support to provide upright postural stability. To Facilitate Training in Skills Normal functional development can be impeded by impairments of coordination and movement. Orthoses can maintain optimum biomechanical alignment of body segments encased within the orthosis. These effects may enable children to overcome activity limitations by focusing training on unrestricted parts of their bodies over which they have better control. Common training targets include encouraging head control by providing trunk stability or using wrist orthoses to facilitate manual dexterity when grasping objects. For lower limb orthoses, the effects also include influencing external movements acting around proximal joints by altering the line of action of the ground reaction force during standing and walking. 9 There may be some motor learning effect when children repeat movements through the altered sensations provided by the orthosis. 10 TO IMPROVE THE EFFICIENCY OF GAIT Children who are able to achieve upright locomotion must be encouraged to optimize their ability to achieve an efficient gait. Gage 11 has described the prerequisites of normal gait: Stability of the supporting leg during stance phase: requiring an appropriate foot-floor contact area, minimizing the external moments acting on the knee, and creating adequate hip abduction power to prevent the pelvis dropping on the unsupported side. Clearance of the foot from the ground during swing phase: requiring adequate hip and knee flexion and ankle dorsiflexion of the swinging limb. Appropriate prepositioning of the limb at the end of swing phase: created by knee extension and ankle dorsiflexion. Achieving an adequate step length: by hip extension of the stance limb and unrestricted advancement of the swinging limb. Conservation of energy expenditure through reduced excursion of the center of mass of the body. Lower limb orthoses may improve gait efficiency by restoring these prerequisites through the manipulation of forces acting on the body. Orthoses may reduce energy expenditure further by decreasing the need for compensatory gait deviations to achieve locomotion. ASSESSMENT A thorough assessment of the child’s needs is essential. The needs of each child will be influenced by the severity of their impairment and their individual activity limitations. The consensus conference document considered orthotic intervention as relating to three levels of function (i) the prestanding child (recognizing that this may be the highest level of activity for some children), (ii) the standing child, and (iii) the walking child. 6 Collating the information required to define the treatment goals and therefore decide whether an orthosis will form a useful part of an overall physical management plan is a multidisciplinary task. The information required will usually include a precise diagnosis using the SCPE classification; functional gross motor status using the GMFCS; measurement of ranges of joint motion both passively and actively; selective muscle control, strength, and spasticity; and joint congruency and integrity judged by radiological investigation. In addition, an assessment of sitting and standing balance and gait analysis will be required for children with those abilities. Other factors influencing the development of a realistic plan for physical management include considering the environments in which the child interacts, behavioral characteristics, and any relevant associated conditions, such as epilepsy, gastroesophageal reflux, or the need for gastrostomy feeding tube access. Once the treatment goals are defined, many therapeutic interventions other than orthoses are available, such as oral, intramuscular, or intrathecally administered medications, orthopaedic and neurological surgery, physical and occupational therapy, wheelchairs, walking aids and other assistive technology, and temporary splinting and casting. These interventions may be prescribed either as more efficacious and appropriate in achieving the treatment goals or to supplement and reduce the demands required of an orthosis. However, children with CP are frequently prescribed orthoses. A follow-up study of a population of children between 5 and 16 years old demonstrated that half the children were prescribed some orthosis in a 9-month period. 12 This study is likely to have underestimated orthotic prescription, because the study period was shorter than the average time (10 months) in which some children outgrow their orthoses. 13 Whatever the treatment goals and design of orthosis selected, a family-centered approach will encourage appropriate use of an orthosis within the prescribed treatment regimen. The health care team, including the orthotist, must therefore be well coordinated, work in partnership with the family, provide adequate general and specific information about the condition and the role of the prescribed orthosis, and support the family to ensure the orthosis is used correctly. 14 ORTHOTIC PRESCRIPTION Following the earlier recommendation to distinguish the needs of the prestanding, standing, and walking child, this review will also attempt to describe the appropriate orthotic management of children with CP with reference to the GMFCS. PRESTANDING GMFCS Level V, Level IV up to Age 6 Years, and Level III Before Age 2 Years Prestanding children will spend all their time in either lying or sitting postures. Based on earlier work to develop systematic assessment protocols, 15 the Chailey scales of ‘levels of ability’ in lying, sitting, and standing provide another framework for assessing the progress of children with postural impairments. 16 Achieving the sequence of postural tasks set out in the Chailey scales requires the child to accomplish discrete improvements in motor development and mastery of balance and coordination. The acquisition of skills or alternatively the provision of postural management aids, which enable independent lying, sitting, and standing, can free the senses and upper limbs from stabilizing the body, promoting activities of dexterity and oromuscular function, thereby facilitating and lying and are in orthoses because they forces to the body to for the they are the of this because they are of assistive usually through the orthotic The children considered in this are the most limited and will usually have and CP. children with CP who are more limited in their activities are at of and therefore Children with lower levels of to children with GMFCS levels IV and V, are at of also to be by the effects of gravity when affected are in the sitting orthoses may reduce spinal and improve sitting ability the orthosis is are to the rate of progressive For children with structural may be the more realistic intervention to for spinal orthoses is to the effects of gravity. the treatment is to enable a and functional sitting may be as demonstrated by a reduced can reduce the by the pelvis Children with levels of sitting ability may also trunk or orthoses may prevent and one study has that the with a spinal orthosis may in improve Hip The of hip and is also associated with activity limitations. Hip requiring treatment 5 years was more in children with CP who were with those who 10 by perhaps children in GMFCS III to Orthoses can be used to and the hip joint to increase of the head in the and hip the to increase the size of the base of support and of the that the center of gravity of the upper body within the support area, also sitting stability. For the of the in controlling the position of the center of gravity and stabilizing the trunk as a can be with hip abduction orthosis providing a Hip abduction spinal orthoses may be used in conjunction with or as to the the child to in The of a orthosis, around the and to with an orthotic hip joint that can be at of hip flexion In this orthosis, external control of sitting posture is the hip joint can also be with the hip the can be useful for all the activities of lying, sitting, and It is also that although these will the child in a hip deformities must be Therefore, may be necessary to provide an hip position to maintain In some knee are used to an force the to the hip in a further to prevent the of the as a sitting orthosis, is that can the of progressive hip and may be necessary if is A and design can be using the orthotic hip However, the of the design is by limited control of the pelvis and trunk and will usually a spinal Hip abduction spinal orthoses of a orthosis to the trunk as a with hip abduction to provide a Hip Orthoses hip for children with CP, hip have been applied and set at of hip abduction and of hip Hip time to at the end of an often of the during the and can such as Other of hip are the need for and usually to ranges of hip and knee joint motion that will have from in the The use of an orthosis in these may overcome some of the associated with using hip The most design in these a to the with an orthotic joint that of flexion and abduction that can be and in the position orthotic joint that of hip flexion and abduction can be an orthosis as an to a hip hip Prestanding children will spend of their time sitting and are therefore to of the muscles of the lower limb. of the muscles around the knee, and ankle two joints. For the of the muscle is the which both the ankle and To provide an efficient of the flexion must be with an orthosis to the This may be by using a ankle foot orthosis and a knee for of the and can develop when the range of dorsiflexion available at the ankle is reduced either by muscle or Mobile and ankle foot deformities can be corrected during the and and the position maintained using Fixed must be accommodated in their corrected ankle and knee deformities secondary to may from of A to often with periods of to facilitate management in orthoses. foot and ankle posture will enable more posture in by some of the of the lower limbs to be by ankle and foot deformities of can a problem and may be motor control and coordination may manual dexterity and may to muscle shortening and reduced ranges of at the and Children with CP may be more affected in their lower limbs with useful function in the upper limbs or have limb The of orthotic management are the as in the lower limbs to in combination with A and wrist orthoses may also be to enable or improve The of functional may be useful to enable or improve function in conjunction with occupational regimens to facilitate training in skills of dexterity A wrist orthosis with and wrist extension the child to on dexterity GMFCS Level Before Age 2 Years, Level III Age 2 Years, and Level IV Age 4 Years The of orthotic management for the standing child are the as for the prestanding child, with the additional of facilitating an efficient upright posture with the appropriate external for the child, may be for the body structure by increasing bone The activity of standing is also important for stretching muscles and other tissues and to children to the from the as their The level of each child’s individual activity limitation will the degree and of external support therefore include of the standing posture and balance For most children who will achieve standing Level a hip knee ankle foot orthosis will be required to maintain an upright Chailey Level 4 for standing force are used to prevent hip and knee applied to the and This may be to a support base as a standing and used with a at an appropriate children are able to adequate hip extension the can be for Children will often support of the ankle and foot to provide stability at the foot-floor during and any secondary or or can either be corrected or accommodated in can be used to the of the lower leg relative to the to flexion of the and or Children who are able to upright and maintain standing by on to an of may from some external support Level 2 Level III 2 Orthoses that ankle motion can be used to provide a base and control the line of action of the ground reaction force around the hip and knee that training and can be at proximal 10 In a study of standing balance, the center of the foot was more for children with than for normal as be and that flexion the children to the center of more little effect on study children with CP with healthy children during standing balance and with and This study demonstrated the children with CP have in muscles to maintain balance and that can impose further by the postural that can be at the In other that have the activity of from sitting to standing, children with CP and who were than healthy children the with either or GMFCS and However, children who were within 1 of the range of normal children in achieving the were when using either design of orthosis GMFCS Level Therefore, of at the ankle may standing balance and enable the child to from sitting to standing more Children who achieve independent standing can on developing skills of perhaps requiring of orthoses and walking aids III and GMFCS and III Age 2 Years and Level IV Age 4 Years two of children with CP will achieve some level of walking The of orthotic management for the walking child are the as for the prestanding and standing child, with the additional to enable the child to an efficient and gait. In to the information required in the of prestanding and standing child, an assessment of the child’s gait is The gait of children with CP is from step to However, children with or of CP may be more and analysis requires a systematic approach to describe the of joint motion and factors that The in the gait of children with CP is that the impairment gait deviations in each of the and and involves the knee, and ankle joints. for children with identified with increasing to proximal For 1 which as only in swing either a or with a flexion may improve foot ground For 2 when in stance and swing and the knee is during a is For and when additional knee and hip orthotic management is and orthopaedic is and identified of knee motion in In combination with these have been used to for physical management that appropriate use of and orthotic for orthotic intervention to improve gait efficiency are usually on the integrity of the extension during stance This describes the normal between the complex and the knee joint to maintain the ground reaction force in of the knee during stance It requires the ankle and foot to be in the line of and the and muscles to control 11 Children with CP with ankle contact with the during walking will usually the line of action of the to well in of the knee and hip an external knee extension perhaps and a flexion around the that prevent and have been can the line of action of the to reduce the resulting abnormal moments around the knee and hip prevent knee and increase hip extension contact with the secondary to abnormal movements around the knee and hip knee that prevent can the line of action of the to reduce the external on the of the with can further the of the orthosis by the knee joint to the children with more of proximal muscles will the knee and hip joints to during the the knee, the external flexion will knee flexion and that prevent dorsiflexion at the ankle can prevent knee flexion during stance by the in of the knee However, whereas these orthoses are effective for the of or flexion at the knee and hip joints means that other interventions are required to these orthoses effective in children with CP. use to the in the 6 to the muscles and enable standing and the to the knee, the external will knee flexion and that prevent dorsiflexion at the ankle can prevent knee flexion during stance by the in of the knee to assist either of the the of the ankle and foot must also with and external dorsiflexion The structure of the ankle and foot may to the applied or and In these dorsiflexion will at the of the structure of the ankle and Therefore, when the integrity of the ankle and foot is to maintain a and the and is at of may be as important to prevent dorsiflexion as well as flexion using a clinicians are that orthoses may impose additional activity orthoses continue to normal of joint have therefore to the of and A review of the of orthoses for children with CP only that flexion gait flexion has been shown to improve stability in stance in swing prepositioning in swing and to increase step length and walking There is a that may also improve energy expenditure on There is to support any effect on gait from orthoses that Therefore, the of orthoses that provide to prevent flexion to little in the to improve gait However, and foot orthoses may be to children with or of cerebral palsy gait deviations are an for achieving or for children during gait has been and deviations in the and are more to distinguish than those in the using only gait in children with CP, which is associated with or hip either compensatory flexion of the limb or caused by in hip on the limb and hip abduction of the shorter and can be corrected using a or foot deformities can the of the foot in to the line of or than hip when is in conjunction with the to when in the This frequently in children with CP because of skeletal of the and for children is more than hip or at the hip Hip abduction orthoses for children may therefore be of little may be possible to forces from the and the shape of the soft tissues to some control using a in control of the hip joint using orthoses requires extension to the Orthoses a within the of a or around the limb to active forces and can the foot However, when the of hip is or orthoses are because the applied can to on the soft tissues of the knee Therefore, deformities usually a or may also from or foot deformity when may be in the long bones. Mobile deformities of with associated and with associated abduction can be corrected during the and using in which the child with the is part of the primary neurological impairment and cannot be influenced by orthotic TO ORTHOTIC To all the of orthoses for walking children with CP have of and all one have used The to support specific orthotic interventions for children with CP to be demonstrated using more such as with appropriate follow-up The in in this population are well in that CP is a condition with a wide range of neurological of children with a can be as an The SCPE 2 and the GMFCS 4 now enable to balance of children of impairments and activity limitations. However, that any between treatment to There is also the of clear and treatment goals and must therefore be in the body structure and activity Other to are the for the and of orthotic and the effects of associated the most problems to overcome are the of clinicians and on the of orthotic interventions that in the of The of most orthotic interventions used in physical management regimens for children with cerebral palsy There to be in the orthotic management of children with CP treatment as a of treatment 12 is that the of orthotic management will be is an for the individual to of that and a to a that may the in the However, to overcome the of individual health care on the over of orthoses must be and using This review has to use the GMFCS as a framework for treatment goals for orthotic management for children with CP. Health care and physical management on valid and reliable such as the GMFCS help the and of interventions for children with a of activity limitations. the of orthotic intervention to prevent deformities must be overcoming activity limitations. the of these of health must be further using