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Ankle foot orthoses for gross motor skills

Last update: 13 Dec 2016

► Ankle foot orthoses (AFOs) are removable splints or braces that support the feet, ankles and lower leg of children with cerebral palsy
► They may help children with everyday skills like walking, running, jumping and climbing stairs
► Ankle foot orthoses are also used to reduce pain and prevent deformity of the foot and ankle1-2 but these outcomes are not included in this review.

Who are these for?

Ankle foot orthoses may be suitable for children with cerebral palsy who have the following characteristics:
Age: Infants and Toddlers, Preschoolers, School-aged, Adolescents, Adults, Older adults
Type of cerebral palsy : Bilateral cerebral palsy, Diplegia, Hemiplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.

Mobility : GMFCS I, GMFCS II, GMFCS III, GMFCS IV, GMFCS V

Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

GMFCS Level I
Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

GMFCS Level II
Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

GMFCS Level III
Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

GMFCS Level IV
Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

GMFCS Level V
Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.

Arm ability : MACS I, MACS II, MACS III, MACS IV, MACS V

Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

MACS Level II
Handles most objects but with somewhat reduced quality and/or speed of achievement.

MACS Level III
Handles objects with difficulty; needs help to prepare and/or modify activities.

MACS Level IV
Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

CFCS Level II
Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

CFCS Level III
Effective Sender and Receiver with familiar partners.

CFCS Level IV
Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

Movement disorder : Ataxia, Athetosis, Dystonia, Hypotonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability, Severe intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

Who can assist?

Ankle foot orthoses are custom made by orthotists through the public hospital system, or private providers. To receive an ankle foot orthosis through the public system, a referral from a doctor within the hospital is usually required. Some orthotic departments may accept referrals from other health professionals such as physiotherapists.

A physiotherapist provides regular support to the child and family after it is fitted, to assist with developing gross motor abilities, mobility and independence.

Physiotherapists at Cerebral Palsy Alliance are skilled at working with children with gross motor difficulties and will help determine if an ankle foot orthosis is a suitable choice.

Find a Cerebral Palsy Alliance service

Fees

The price for ankle foot orthoses from private orthotists varies depending on type and starts at AUD$600 each. Ankle foot orthoses provided by a public hospital are funded by the health system and are generally free of charge to children and families.

Fees will apply for a physiotherapist to provide assessment and support, and will depend on the service provider and number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing or therapist travel.

Ask the service provider if you are eligible for funding to assist with physiotherapist fees and AFOs. People with disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

Time

Two to three visits to the orthotist are generally required to make, fit and review the device. It may take time and practice for a child to adjust to using ankle foot orthoses.

More about ankle foot orthoses

Ankle foot orthoses may be recommended to help children with cerebral palsy improve gross motor skills such as running and jumping. These removable splints or braces are fitted to the foot, ankle and lower leg and control the position of the foot and ankle.

Features of ankle foot orthoses

Ankle foot orthoses are:

  • Custom-made to fit individual children
  • Extend from under the foot, to just below the knee to provide support around the foot and ankle
  • Are held in place with straps and worn with shoes and socks
  • Come in different styles

The most common type for children with cerebral palsy are:

  • Solid/rigid ankle foot orthoses, which don’t allow any movement at the ankle
  • Hinged/dynamic ankle foot orthoses, which allow some movement at the ankle.

Specific footwear may also be prescribed to wear with an ankle foot orthosis.

Other recommended therapies

Ankle foot orthoses are usually just one part of a broader treatment program. Other therapies often recommended to be used alongside ankle foot orthoses may include goal directed training, serial casting and botulinum toxin-A injections. Click here for detailed information on Goal Directed Training.

Assessments

There are two types of assessment which are required as part of using ankle foot orthoses:

To guide intervention

The decision to prescribe an ankle foot orthosis is made with a multidisciplinary team including the child and family, orthotists, physiotherapists and doctors. A comprehensive assessment, usually completed by a physiotherapist will identify each child’s needs, help a family to set goals and advise on the right kind of orthoses.

To measure the outcome of the intervention

An outcome measure should be used to determine whether this intervention has met the child’s needs and goals. Commonly used outcome measures include:
  • Gross Motor Function Measure (GMFM) – measures change over time in children’s gross motor abilities (such as standing, walking, running and jumping)
  • Goal Attainment Scaling (GAS goals) – measures the extent to which individuals’ goals are achieved and can be used to measure change in gross motor ability
  • Timed Up and Go test – tests mobility and balance by measuring time taken to stand up, walk three metres, turn around and sit down again
  • Six Minute Walk test – measures mobility by the distance a child can walk in six minutes
  • Range of Motion – the amount of movement at the ankle, knee and hip
  • 2D Gait analysis – video assessment to observe changes in the way the ankle, knee and hip move during walking.

Best available research evidence

Where did we search?

We searched the medical and allied health literature to find research evaluating the outcomes of ankle foot orthoses for children with cerebral palsy at GMFCS Levels I, II and III.

What were we looking for?

The search aimed to find the best available evidence as to whether this intervention improves gross motor abilities such as walking, running, jumping and climbing stairs. Research evaluating the impact of ankle foot orthoses on deformity, pain, gait kinematics (joint angles), kinetics (joint forces) and the temporal parameters of gait (such as speed, cadence and step length) was excluded.

The literature relating to children with hemiplegia and children with diplegia was considered separately.

What did we find?

Children with hemiplegia

The best available evidence was one Level 3 study comparing walking without ankle foot orthoses with three different ankle foot orthoses3-4. Thirty children, aged five years old to 16 years old, who were able to walk independently without assistive devices (GMFCS Level I and II) were included. Each child was assessed following a three-month period of walking without an ankle foot orthosis and of wearing each of three different types of ankle foot orthoses.

The Gross Motor Performance Measure (GMPM) and the Standing (Dimension D) and Walking, Running, Jumping (Dimension E) sections of the Gross Motor Function Measure (GMFM) were used to evaluate gross motor function. The Functional Skills-Mobility domain of the Pediatric Evaluation of Disability Inventory (PEDI) was also used.

There was no change on GMFM for no orthosis or any of the three ankle foot orthoses. Children’s coordination and weight shift abilities (GMPM) and functional mobility skills (PEDI) were significantly better when using an ankle foot orthoses than not wearing an orthosis. The authors concluded that ankle foot orthoses improve the performance of motor skills that have already been mastered rather than helping a child gain new skills.

Overall, the results are not conclusive, but suggest ankle foot orthoses could assist children with hemiplegic cerebral palsy to improve their existing motor skills. The quality of evidence on the use of ankle foot orthoses to improve gross motor function in children with spastic hemiplegia at GMFCS Levels I and II is considered low as there is only one, low level study.

Children with diplegia

The best available evidence was one Level 2 study4 (randomised controlled trial) and two Level 3 studies5,6. A total of 61 children were involved across the three studies, with ages ranging between four years old and 11 years old. GMFCS Levels I, II and III were represented by 31, 25 and five children respectively. The methodology differed across all three studies, however, each compared gross motor function across three conditions – without an orthosis, solid ankle foot orthoses and hinged ankle foot orthoses. Participants in the Dalvand et al.4 study also received three one-hour sessions per week of neurodevelopmental therapy for three months. Participants in the Buckon et al.5 study did not receive any physical therapy during the study, whilst Smith et al.6 did not report on the provision of concurrent physical therapy. The Standing (Dimension D) and Walking, Running, Jumping (Dimension E) sections of the GMFM were used to evaluate the effectiveness of ankle foot orthoses in all three studies. GMFM scores (Dimensions D and E combined) were reported to improve in all conditions in the Dalvand et al. study4, but there was no difference in the amount of improvement between the three conditions. There was no improvement on Dimension D or E in any of the conditions in the study by Smith et al.6, whilst Buckon et al.5 reported a clinically significant improvement for Dimension E (but not D) for both ankle foot orthoses conditions compared with no orthosis. In addition, Buckon et al.5 used the PEDI and GMPM, and Smith et al.6 used the Pediatric Outcomes Data Collection Instrument to measure outcomes. No significant changes were detected on these measure for any of the conditions in either study.

Overall, it is not clear whether ankle foot orthoses improve gross motor abilities for children with diplegic cerebral palsy. This is because the quality of evidence addressing the use of ankle foot orthoses to improve gross motor function in children with spastic diplegia was considered very low, due to inconsistencies in methodologies and results across the three studies. The differences were in population group (age and GMFCS level), ankle foot orthoses design, and duration of follow up periods.

The fact that little and low quality research has been completed about the effects of ankle foot orthoses should not deter children with cerebral palsy, their families, caregivers and physiotherapists from carefully considering the unique goals and needs of each person with assisting gross motor skills. Ankle foot orthoses will work well for some children with cerebral palsy but will not be right for everyone.

Date of literature searches: July 2016

  1. Morris, C. (2002). Orthotic management of children with cerebral palsy. Journal of Prosthetics and Orthotics, 14(4),150-158.
  2. Ankle-Foot Orthoses AFOs. Retrieved December 9, 2014, from http://www.rch.org.au/orthotic/info_for_parents/AnkleFoot_Orthoses_AFOs/
  3. Buckon, C., Sienko Thomas, S., Jakobson-Huston, S., Moor, M., Sussman, M. & Aiona, M. (2001). Comparison of three ankle-foot orthosis configurations for children with spastic hemiplegia. Developmental Medicine & Child Neurology, 43(6),371-378 doi: 10.1017/S0012162201000706
  4. Dalvand, H., Dehghan, L., Feizi, A., Hosseini, S.A. & Amirsalari, S. (2013). The impacts of hinged and solid ankle-foot orthoses on standing and walking in children with spastic diplegia. Iranian Journal of Child Neurology, 7(4), 12-19 S0012162201000706
  5. Buckon, C., Sienko Thomas, S., Jakobson-Huston, S., Moor, M., Sussman, M. & Aiona, M. (2004). Comparison of three ankle-foot orthosis configurations for children with spastic diplegia. Developmental Medicine & Child Neurology, 46(9),590-598 doi: 10.1017/S0012162204001008
  6. Smith, P.A., Hassani, S., Graf, A., Flanagan, A., Reiners, K., Kuo, K., Roh, J. & Harris, G. (2009), Brace evaluation in children with diplegic cerebral palsy with a jump gait pattern. Journal of Bone and Joint Surgery. American Volume, 91(2), 356-365 doi: 10.2106/JBJS.G.01369
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