Day vs. Day-Night Use of Ankle-Foot Orthoses in Young Children with Spastic Diplegia: A Randomized Controlled Study

Efficacy of Lower Limb Orthoses in the Rehabilitation of Children Affected by Cerebral Palsy: A Systematic Review

Lower limb orthoses are frequently used in children suffering from cerebral palsy (CP) alongside rehabilitation. The aim of this study was to analyze the effectiveness of ankle-foot orthosis (AFO) and knee-ankle-foot orthosis (KAFO) in walking, balance maintenance, spasticity, and quality of life improvement during rehabilitation in children affected by CP. The hypothesis was that the use of orthoses could improve the parameters compared to non-use. A systematic review was conducted in the main databases, including English language RCTs published about the use of AFO and KAFO in combination or not with rehabilitation methods in children affected by CP and studies mentioning walking, balance, muscle length, and quality of life as outcomes. From an initial number of 1484 results, a final number of 11 RCTs were included, comprising a total number of 442 participants and showing an overall high risk of bias in 10 studies and some concerns in one study. Six studies investigated the domain of walking, four studies investigated the domain of balance, and two studies investigated how KAFO and AFO orthoses could improve and prevent muscle contractures. Using highly heterogeneous study designs, different kinds of orthoses and different assessment tools were used. Further studies conducted with higher methodological quality are needed to establish whether AFO and KAFO are useful or not in combination with rehabilitation in improving the investigated domains.

Early Cerebral Palsy Detection and Intervention

Early identification of cerebral palsy (CP) facilitates optimal care, support, and outcomes for children and their families. Ideally, infants with risk factors or developmental deviations should be evaluated early using standardized assessments of neurodevelopment and brain imaging. If a diagnosis of CP or high risk for CP (HRCP) is established, specialized, evidence-informed therapy and family support should be initiated. With task-specific motor skill training and an enriched environment, infants with CP show greater gross motor and cognitive gains. These enhanced outcomes are only achievable with early diagnosis and subsequent intervention.

Assessment of Five-Foot Plantar Morphological Pressure Points of Children with Cerebral Palsy Using or Not Dynamic Ankle Foot Orthosis

People with spastic cerebral palsy (CP) often experience a decline in gait function and flexion. The children's posture and hip strategy, which leads to knee flexion, predisposes these children to increased contact area in the medial foot region. This study investigated the use of DAFO (dynamic ankle-foot orthosis) prescribed to patients with cerebral palsy (CP) to determine the plantar pressure distribution with orthosis use. Eight children with spastic CP (age 4-12 years) were classified as Gross Motor Function Classification System (GMFCS) levels I-II with a maximum spasticity level of 3 in their ankle muscles according to the Modified Ashworth Scale. We assessed the plantar distribution by using eight WalkinSense sensors in each trial and exported data from the proprietary software (WalkinSense version 0.96, Tomorrow Options Microelectronics, S.A.). The plantar pressure distribution was conducted under two conditions: only shoes and DAFO with shoes. The activation percentages for sensor number 1 under the 1st metatarsal and sensor number 4 under the lateral edge of the heel were significantly different under the DAFO condition. The 1-point sensor activation percentage significantly decreased, while the 4-point sensor activation percentage increased during DAFO walking. According to our study findings, there was an increase in pressure distribution in the lateral part of the foot during the stance phase in DAFO. DAFO improved the gait cycle and influenced the plantar foot pressure in children with mild cerebral palsy.

Passive Articulated and Non-Articulated Ankle-Foot Orthoses for Gait Rehabilitation: A Narrative Review

The aim of this work was to study the different types of passive articulated and non-articulated ankle-foot orthoses for gait rehabilitation in terms of working principles, control mechanisms, features, and limitations, along with the recent clinical trials on AFOs. An additional aim was to categorize them to help engineers and orthotists to develop novel designs based on this research. Based on selected keywords and their composition, a search was performed on the ISI Web of Knowledge, Google Scholar, Scopus, and PubMed databases from 1990 to 2022. Forty-two studies met the eligibility criteria, which highlighted the commonly used types and recent development of passive articulated and non-articulated ankle-foot orthoses for foot drop. Orthotists and engineers may benefit from the information obtained from this review article by enhancing their understanding of the challenges in developing an AFO that meets all the requirements in terms of ease of use, freedom of movement, and high performance at a relatively low cost.

Comparison of body structure, function, activity, and participation levels according to ankle foot orthosis wearing time in children with spastic cerebral palsy

BACKGROUND

Ankle foot orthoses (AFOs) are usually recommended to prevent deformities and to increase the standing and walking performance in children with spastic cerebral palsy (CP).

OBJECTIVE

To compare the body functions and structures, activity and participation levels, and environmental factors according to AFO-wearing time in children with spastic CP.

STUDY DESIGN

Prospective, cross-sectional-observational-clinical study.

METHODS

Eighty children with spastic CP (Gross Motor Function Classification System I-III; mean age 7.3 ± 3.9 years) were divided into two groups with equal ages and duration of AFO usage, which is provided as a part of routine clinical care: 6-12 hours per day group (n = 40) and 12-24 hours per day group (n = 40). The outcomes measured were calf muscle's spasticity with the modified Ashworth Scale (MAS), passive ankle dorsiflexion angle (DA), 66-item Gross Motor Function Measurement, Pediatric Berg Balance Scale, and Pediatric Quality of Life Inventory (PedsQL). Parental satisfaction was measured with a Visual Analog Scale. Multifactorial ANOVA was used to compare the groups, corrected for 66-item Gross Motor Function Measurement.

RESULTS

No significant differences for the Pediatric Berg Balance Scale, MAS, and DA were found between the groups. Significant differences for the PedsQL (76.99 vs. 57.63; mean difference [MD], 15.60; 95% confidence interval [CI], 10.99∼20.22), daily living activities (65.30 vs. 35.92; MD, 25.72; 95% CI, 17.58∼33.86), fatigue (76.9 vs. 56.85; MD, 23.11; 95% CI, 16.87∼29.35), and satisfaction (8.08 vs. 5.21; MD, 2.46; 95% CI, 1.64∼3.27) were found between the groups; 6-12 hour group had superiority for each outcome (P < 0.001). Wearing time was significantly correlated with PedsQL (r = -0.524, P < 0.001) and satisfaction (r = -0.521, P < 0.001) but not with MAS or DA.

CONCLUSIONS

AFO-wearing time seems to depend on the child's activity and participation levels rather than body functions and structures in children with spastic CP. Prolonged AFO-wearing time was negatively correlated with both the activity-participation level and parental satisfaction.

Effects of Ankle Foot Orthoses on the Gait Patterns in Children with Spastic Bilateral Cerebral Palsy: A Scoping Review

BACKGROUND

Cerebral palsy (CP) is the most common cause of motor disability in children and can cause severe gait deviations. The sagittal gait patterns classification for children with bilateral CP is an important guideline for the planning of the rehabilitation process. Ankle foot orthoses should improve the biomechanical parameters of pathological gait in the sagittal plane.

METHODS

A systematic search of the literature was conducted to identify randomized controlled trials (RCT) and controlled clinical trials (CCT) which measured the effect of ankle foot orthoses (AFO) on the gait of children with spastic bilateral CP, with kinetic, kinematic, and functional outcomes. Five databases (Pubmed, Scopus, ISI Web of SCIENCE, SciELO, and Cochrane Library) were searched before February 2020. The PEDro Score was used to assess the methodological quality of the selected studies and alignment with the Cochrane approach was also reviewed. Prospero registration number: CRD42018102670.

RESULTS

We included 10 studies considering a total of 285 children with spastic bilateral CP. None of the studies had a PEDro score below 4/10, including five RCTs. We identified five different types of AFO (solid; dynamic; hinged; ground reaction; posterior leaf spring) used across all studies. Only two studies referred to a classification for gait patterns. Across the different outcomes, significant differences were found in walking speed, stride length and cadence, range of motion, ground force reaction and joint moments, as well as functional scores, while wearing AFO.

CONCLUSIONS

Overall, the use of AFO in children with spastic bilateral CP minimizes the impact of pathological gait, consistently improving some kinematic, kinetic, and spatial-temporal parameters, and making their gait closer to that of typically developing children. Creating a standardized protocol for future studies involving AFO would facilitate the reporting of new scientific data and help clinicians use their clinical reasoning skills to recommend the best AFO for their patients.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews

IMPORTANCE

Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years.

OBJECTIVE

To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.

EVIDENCE REVIEW

The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument.

FINDINGS

Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5).

CONCLUSIONS AND RELEVANCE

When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Assessments and Interventions for Spasticity in Infants With or at High Risk for Cerebral Palsy: A Systematic Review

BACKGROUND

The majority of children with cerebral palsy develop spasticity, which interferes with motor development, function, and participation. This systematic review appraised current evidence regarding assessments and interventions for spasticity in children aged less than two years with or at high risk for cerebral palsy and integrated findings with parent preferences.

METHODS

Five databases (CINAHL, EMBASE, OVID/Medline, SCOPUS, and PsycINFO) were searched. Included articles were screened using PRISMA guidelines. Quality of the evidence was reviewed by two independent reviewers using Quality Assessment of Diagnostic Accuracy Studies, second edition (QUADAS-2), the RTI Item Bank on Risk of Bias and Precision of Observational Studies (RTI), or The Cochrane Collaboration's tool for assessing risk of bias in randomized trials (RoB). An online survey was conducted regarding parent preferences through social media channels.

RESULTS

Twelve articles met inclusion criteria. No high-quality assessment tool emerged for this population. Six interventions (botulinum toxin-A, orthotic use, radial extracorporeal shock wave therapy, erythropoietic stimulating agents, medical cannabis, and homeopathy) were identified. There was low-quality evidence for the use of botulinum toxin-A and radial extracorporeal shock wave therapy to improve short-term outcomes. Survey respondents indicated that spasticity assessments and interventions are highly valued, with nonpharmacologic interventions ranked most preferably.

CONCLUSIONS

Further research is needed to validate assessments for spasticity in children younger than two years. Conditional recommendations can be made for botulinum toxin-A and radial extracorporeal shock wave therapy based on low level of evidence to reduce spasticity in children aged less than two years.

The mechanisms of adaptation for muscle fascicle length changes with exercise: Implications for spastic muscle

We are proposing optimal training conditions that can lead to an increase in the number of serial sarcomeres (SSN) and muscle fascicle length (FL) in spastic muscles. Therapeutic interventions for increasing FL in clinical populations with neurological origin, in whom relative shortness of muscle fascicles contributed to the presentation of symptoms such as spasticity, contracture, and limited functional abilities, do not generally meet these conditions, and therefore, result in less than satisfactory outcomes. Based on a review of literature, we argue that protocols of exercise interventions that led to sarcomerogenesis, and increases in SSN and FL in healthy animal and human models satisfied three criteria: 1) all involved eccentric exercise at appropriately high velocity; 2) resulted in positive strain of muscle fascicles; and 3) momentary deactivation in the stretched muscle. Accordingly, to increase FL in spastic muscles, new exercise protocols in which the three presumed criteria are satisfied, must be developed, and long-term muscle architectural and functional adaptations to such trainings must be examined.

Wearing Time of Ankle-Foot Orthoses with Modular Shank Supply in Cerebral Palsy: A Descriptive Analysis in a Clinically Prospective Approach

Objective

To date there is only limited knowledge about the wearing time of orthoses. Ankle-foot orthoses (AFOs) have not been studied with this research question. Additional influences of the orthotic design as well as weekdays and the weekend are also unknown.

Design

Monocentric, clinically prospective intervention study.

Patients

Inclusion of 10 patients with bilateral spastic cerebral palsy.

Methods

Equipment of all subjects with a dynamic ankle-foot orthosis (DAFO) and modular shank supply (MSS, dynamic elastic shank adaptation or ground reaction AFO). Integration of temperature sensors for recording the wearing time for a period of 3 months.

Results

The actual wearing time was below the recommendations on actually worn days as well as the average of the entire study period. In addition, the actual usage in terms of days and hours was well below the recommendations. The wearing time showed differences between weekdays and weekend. Differences between DAFO and MSS were not detectable.

Conclusion

The actual usage behavior of ankle-foot orthoses differs from the recommendations of the prescriber. This applies to both DAFOs and modular use with shank supplies. Environmental factors may have a significant impact on wearing times on weekdays and the weekend.

Ankle foot orthoses for young children with cerebral palsy: a scoping review

AIM

To describe research on outcomes associated with early Ankle Foot Orthosis (AFO) use, AFO use patterns, and parent and clinician perspectives on AFO use among young children with cerebral palsy.

METHOD

Arksey and O'Malley's five-stage method was used to conduct a scoping review. MEDLINE (Ovid), PubMed, CINAHL, Cochrane Database of Systematic Reviews, EMBASE, PEDro, Web of Science and Scopus were searched for studies evaluating AFO use with children under the age of six years. Descriptive information was extracted and outcomes categorized according to the International Classification of Functioning, Disability and Health (ICF). Quality assessments were conducted to evaluate methodological rigor.

RESULTS

Nineteen articles were included in the review; 14 focused on body functions and structures, seven on activity level outcomes and no studies addressed participation outcomes. Evaluations of the effects of AFOs on gross motor skills other than gait were limited. Overall, the body of evidence is comprised of methodologically weak studies with common threats to validity including inadequate descriptions of study protocols, AFO construction, and comparison interventions.

CONCLUSION

Research evaluating the effects of AFOs on age-appropriate, functional outcomes including transitional movements, floor mobility and participation in early childhood settings is needed to inform practice regarding early orthotic prescription. Implications for rehabilitationLack of rigorous evidence about the effects of AFOs in young children limits the ability of research to guide practice in pediatric rehabilitation.More rigorous research that evaluates a broader range of age-appropriate outcomes, including those focused on participation in meaningful activities, could further inform clinical practice.While clinicians often discuss expectations and goals with individual families, qualitative research that provides more insight into the experiences of families could guide AFO prescription and monitoring practices.

Efficacy of prefabricated carbon-composite ankle foot orthoses for children with unilateral spastic cerebral palsy exhibiting a drop foot pattern

PURPOSE

This study aims to evaluate the effectiveness of a prefabricated carbon-composite ankle foot orthoses (c-AFOs) on gait parameters in children with unilateral spastic cerebral palsy (USCP) exhibiting a drop foot pattern.

METHODS

Sixteen ambulatory children with USCP and a drop foot pattern were included (mean age: 9 years; gross motor function classification system: I = 14, II = 2) and three-dimensional gait analysis was applied under randomly assigned conditions (barefoot; shoe; c-AFO). Kinematics, kinetics, time-distance parameters and gait indices were investigated.

RESULTS

Effects on the drop foot pattern were investigated while the children walked in shoes only. The shoes already increased the maximum ankle dorsiflexion in swing (p= 0.004) and initiated more knee flexion during single support (p⩽ 0.013). Compared to shoe walking, the c-AFO led to additional benefits regarding further ankle dorsiflexion during swing (p⩽ 0.001) and initial contact (p< 0.001), ankle movement during loading response (p= 0.002), improved the sole angle during initial contact (p< 0.001) and during mid stance (p= 0.015). Plantarflexion and ankle power generation during push-off decreased when wearing the c-AFO (p⩽ 0.008).

CONCLUSION

Investigated c-AFOs are beneficial for improving drop foot patterns in children with USCP. Significant effects on pathological barefoot pattern were already achieved with the child's regular shoes. This could be considered in clinical decision processes. In comparison to shoe walking, c-AFO additionally improved foot clearance and normalized initial heel contact. The third rocker deteriorates with the c-AFO. Since kinematics improved with the orthoses during swing and early stance phase, c-AFOs might reduce tripping and falling caused by a drop foot during long distance walking.

A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions

BACKGROUND

Assistive products are items which allow older people and people with disabilities to be able to live a healthy, productive and dignified life. It has been estimated that approximately 1.5% of the world's population need a prosthesis or orthosis.

OBJECTIVE

The objective of this study was to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions.

METHODS

Literature searches, completed in September 2015, were carried out in fourteen databases between years 1995 and 2015. The search results were independently screened by two reviewers. For the purpose of this manuscript, only randomized controlled trials which examined interventions using orthotic or prosthetic devices were selected for data extraction and synthesis.

RESULTS

A total of 342 randomised controlled trials were identified (319 English language and 23 non-English language). Only 4 of these randomised controlled trials examined prosthetic interventions and the rest examined orthotic interventions. These orthotic interventions were categorised based on the medical conditions/injuries of the participants. From these studies, this review focused on the medical condition/injuries with the highest number of randomised controlled trials (osteoarthritis, fracture, stroke, carpal tunnel syndrome, plantar fasciitis, anterior cruciate ligament, diabetic foot, rheumatoid and juvenile idiopathic arthritis, ankle sprain, cerebral palsy, lateral epicondylitis and low back pain). The included articles were assessed for risk of bias using the Cochrane Risk of Bias tool. Details of the clinical population examined, the type of orthotic/prosthetic intervention, the comparator/s and the outcome measures were extracted. Effect sizes and odds ratios were calculated for all outcome measures, where possible.

CONCLUSIONS

At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness.

What's New in the Management of Foot Deformities in Children With Cerebral Palsy

BACKGROUND

Foot deformities have been frequently reported in cerebral palsy (CP), and numerous diagnostic modalities and treatment options have recently been developed to achieve a better level of management for children with CP.

METHODS

A thorough search of the English literature, published between January 2013 and March 2016, was performed. A summary of the new findings that had not previously described was reported. The review included recent advances regarding clinical and gait evaluation, orthotic management, botulinum toxin A treatment, and surgical correction.

RESULTS

The review summarized new findings reported in 46 articles and abstracts that were published between January 2013 and March 2016. Older articles were included and cited when an original description was mentioned, or when a change or development of some findings was discussed.

CONCLUSIONS

Foot deformity forms an essential part of evaluating children with CP. Dramatic advances have been achieved in gait assessment, conservative management, and surgical correction. Promising results have been reported with the goal to reach a higher level of orthopaedic care and optimize the functional potentials for children with CP.

LEVEL OF EVIDENCE

Level IV-literature review.

Efficacy of ankle foot orthoses types on walking in children with cerebral palsy: A systematic review

BACKGROUND

Ankle foot orthoses (AFOs) are orthotic devices that can be used to normalize the walking pattern of children with cerebral palsy (CP). One of the aims of orthotic management is to produce a more normal gait pattern by positioning joints in the proper position to reduce pathological reflex or spasticity.

OBJECTIVE

To conduct a systematic review of the literature and establish the effect of treatment with various types of AFOs on gait patterns of children with CP.

METHODS

PubMed, Scopus, ISI Web of knowledge, Cochrane Library, EMBASE and Google Scholar were searched for articles published between 2007 and 2015 of studies of children with CP wearing the following AFOs: hinged (HAFO), solid (SAFO), floor reaction (FRO), posterior leaf spring (PLS) and dynamic (DAFO). Studies that combined treatment options were excluded. Outcomes investigated were a change in gait pattern and subsequent walking ability. The PEDro scale used to assess the methodological quality of relevant studies.

RESULTS

We included 17 studies investigating a total of 1139 children with CP. The PEDro score was poor for most studies (3/10). Only 4 studies, of 209 children in total, were randomized controlled trials, for a good PEDro score (5, 7, 9/10) and an appropriate level of evidence. One study used a case-based series and the remainder a cross-sectional design. In general, the use of AFOs improved speed and stride length. The HAFO was effective for improving gait parameters and decreasing energy expenditure with hemiplegic CP as compared with the barefoot condition. It also improved stride length, speed of walking, single limb support and gait symmetry with hemiplegic CP. The plastic SAFO and FRO were effective in reducing energy expenditure with diplegic CP. With diplegic CP, the HAFO and SAFO improved gross motor function.

CONCLUSION

For children with CP, use of specific types of AFOs improved gait parameters, including ankle and knee range of motion, walking speed and stride length. AFOs reduced energy expenditure in children with spastic CP. However, further studies with good PEDro scores are required for more conclusive evidence regarding the effectiveness of AFOs in children with CP.

Effect of an Ankle Foot Orthosis Intervention for Children With Non-Central Nervous System Cancers: A Pilot Study

PURPOSE

Children with cancer are at risk for physical performance limitations. In this pilot study we investigated the feasibility and initial efficacy of an ankle foot orthosis (AFO) in children with non-central nervous system cancer with peripheral weakness.

METHODS

Participants included children aged 5 to 11 years diagnosed with cancer. Children wore AFOs for 1 cycle of chemotherapy. Pre- and postintervention adverse events, adherence, gait, strength, range of motion, activity, and fatigue were measured.

RESULTS

Six of 7 children completed the study; none of the 7 reported adverse events. Positive trends were observed in step length (46.23-49.25 cm), dorsiflexion strength (19.25-24.50 lb), ankle dorsiflexion range of motion (0.5-8°), and activity (7850-9857 epochs). Negative trends observed included cadence and fatigue ratings. No change was observed in the 6-minute walk or parent-reported fatigue.

CONCLUSIONS

An AFO intervention is feasible in children with cancer. Initial efficacy results warrant further study.

A randomized controlled trial studying efficacy and tolerance of a knee-ankle-foot orthosis used to prevent equinus in children with spastic cerebral palsy

Objective:

To examine whether using a knee-ankle-foot orthosis helps maintain ankle-foot dorsiflexion range of motion over time.

Design:

A multicentre randomized controlled trial.

Setting:

Two hospitals and one rehabilitation centre in the Netherlands and the USA.

Subjects:

Children (4-16 years old) with spastic cerebral palsy who were able to walk.

Intervention:

Use of a knee-ankle-foot orthosis, equipped with an Ultraflex® ankle power unit, for at least 6 hours every other night for one year.

Main measures:

Primary outcome measure: ankle-foot dorsiflexion range of motion. Secondary outcome measures: ankle-foot and knee angle in gait and gross motor function. Wearing time was also measured. Measurements were taken at baseline and at 3, 6, 9 and 12 months.

Results:

28 children (experimental group: n=15, control group: n=13) participated in the study. 11 participants (experimental: n=4, control: n=7) did not complete all five measurements, as they needed additional treatment. No significant difference was found in the decrease of ankle-foot dorsiflexion range of motion between the experimental and control groups (difference: −1.05°, 95% confidence interval: −4.71° – 2.61°). In addition, secondary outcome measures did not show differences between groups. Despite good motivation, knee-ankle-foot orthosis wearing time was limited to a mean±SD of 3.2±1.9 hours per prescribed night due to discomfort.

Conclusions:

Knee-ankle-foot orthosis with dynamic ankle and fixed knee are poorly tolerated and are not beneficial in preventing a reduction in ankle-foot dorsiflexion range of motion in children with spastic cerebral palsy, at least with limited use.