Could Changing our Thinking about Ankle-Foot-Orthotics (AFOs) Help Children Walk Better?

By: Laura Znajda, PT

This is a question many in the pediatric therapy world have been pondering and practicing for a number years.  Elaine Owen, MSc SRP, MCSP has completed quite a lot of research through her work as superintendent and clinical specialist physiotherapist at the Child Development Centre in Bangor, Wales, in the UK.  Through her careful study of the gait cycle, she has inspired us to think differently about the way the segments of the foot and leg are aligned at various times in the cycle, and she encourages us to replicate normal gait more closely through the use of not just an AFO, but AFO/footwear combinations.

AFO
The Old Paradigm: 0 degree plantarflexion AFOs and Flat Shoes. Photo from Beverly Cusick.

In her paper The importance of being earnest about shank and thigh kinematics especially when using ankle-foot orthosis, Elaine points out that contrary to the common belief that the lower leg is vertical at midstance (the way many solid-ankle AFOs are designed), the lower leg is actually inclined 10-12 degrees at this time in the gait cycle, and this inclined position places the knee joint over the center of the foot, which provides stability in single limb stance.  This information begs the question, are we actually causing more work for our clients, as they struggle to move their center of mass forward over an unnatural vertical lower leg position?  Could we increase efficiency and more closely approximate normal gait by adjusting the pitch of the AFO at midstance through the use of specific footwear or external additions to the brace?

AFO graphic
An example of a New Paradigm AFO. Photo from Beverly Cusick

Beverly Cusick, PT, MS, COF/BOC has done much to bring this, among other current concepts, to the attention of practicing pediatric therapists and orthotists.  In her paper, Help Patients Manage Equinus Deformity, Use Orthoses to teach children to optimize body weight carriage on the feet, Ms. Cusick describes a paradigm shift in brace design for children whose ankles are plantarflexed (toes pointed downward) while walking.  In addition to the concepts brought to light by Ms. Owen, Ms. Cusick considers the sensory benefit of gaining full heel loading in the brace as an essential component of the effort to improve postural control in standing and – when feasible – walking all day long. Modified AFOs combined with modified footwear can provide the wearer with a strong biomechanical training tool.

To get acquainted with these concepts, click on the references above and the Progressive Gaitways, LLC website:  www.gaitways.com.

To learn a lot more about how to bring them into your practice, attend a joint education course from Easter Seals DuPage & Fox Valley and Shriner’s Hospital presented by Beverly Cusick, PT, MS, NDT, COF/BOC in May:

For more continuing education information including the course schedule, please visit:  www.eastersealsdfvr.org/continuingeducation.

 

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