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Spasticity in children and young people with non-progressive brain disorders that incorporate different durations and timings of standing frame use. For example, what is the effectiveness of 1 hour per day in a single session compared with two sessions of 30 minutes per day? The research should be conducted in children and aged 1–3 years. These children are likely to benefit the most from using standing frames (in terms of developing well-formed femoral heads and acetabulums) and they should find the use of standing frames acceptable (because they are lighter than older children and they do not have severe contractures). 3 What is the clinical and cost effectiveness of 24-hour postural management programmes in non-ambulatory children and young people with bilateral spasticity affecting all four limbs? 4 What is the optimal duration for the passive stretch component of physical therapy? 5 What is the clinical and cost effectiveness of activity-based context-focused physical therapy compared with child-focused physical therapy in children and young people who are at GMFCS level I, II or III? 6 What is the clinical and cost effectiveness and optimal age for modified constraint-induced movement therapy? 78
5 Orthoses Introduction The term orthosis refers to an externally applied device intended to modify the structural and functional characteristics of the neuromuscular and skeletal systems. An orthosis may be recommended as one of a range of measures to manage the effects of altered muscle tone and associated abnormal postures. The prevention of persistently abnormal postures reduces the risk of musculoskeletal adaptations that lead to fixed structural deformities. Orthoses are often used in conjunction with other interventions such as physical therapy (physiotherapy and/or occupational therapy) or botulinum toxin (BoNT) treatment. They may also be used following orthopaedic surgery. They may be used to facilitate function (for example improving hand use) or to prevent deformity (for example by applying sustained muscle stretch during the night). There are many types of orthosis. This chapter focuses on orthoses used in the management of limb and trunk spasticity. The technology and materials used to construct orthoses is evolving constantly. Orthoses may be manufactured as standard devices for a particular purpose or be custom-made for an individual by an orthotist or other trained professional. Orthoses may be beneficial in terms of enhancing function and posture, but they may have disadvantages too. They may be considered to be unsightly or cause discomfort and pressure injuries and, if used inappropriately, they may affect function adversely. Orthoses may improve gait and facilitate walking. Key considerations when examining the use of orthoses in this setting are the degree of ankle dorsiflexion at initial foot contact (when the foot is first placed on the ground), at stance phase (when the body is aligned above the foot), during terminal stance (when the foot is pushing off the ground) and at floor clearance during the swing phase of the step. Each of these aspects impacts on the child or young person’s gait. Spasticity often interferes with a child or young person’s ability to achieve ankle dorsiflexion (resulting in an equinus foot posture) and this impedes walking. Spasticity can also cause excessive knee or hip flexion resulting in a crouched posture (crouch gait), and this makes walking inefficient and tiring. Children and young people often find that fatigue of this kind impairs their ability to participate in activities with peers. Speed of walking may be used as an indication of gait efficiency, including the ability to keep up with peers. For this review question the following types of orthoses, including several types of ankle–foot orthosis (AFO), were considered: • Solid (or rigid) ankle–foot orthosis (SAFO): this prevents dorsiflexion and plantarflexion. It is used to prevent excessive plantarflexion or knee hyperextension during standing or walking. Knee hyperextension is a common problem which tends to induce foot plantarflexion automatically. • Posterior leaf spring ankle–foot orthosis (PLSAFO): this supports the foot and ankle, preventing excessive plantarflexion. It also provides some flexibility in the foot plate. This enables some passive dorsiflexion and, therefore, aids in the toe-off phase of walking. • Hinged ankle–foot orthosis (HAFO): this incorporates a block that can prevent dorsiflexion or plantarflexion, depending on individual need. For most children and young people the aim is prevention of plantarflexion, but those prone to a crouch gait may benefit from control of dorsiflexion. • Anterior ground reaction force ankle–foot orthosis (GRAFO): this applies forces to the shin in the standing position, which helps to reduce knee flexion and the tendency to adopt a crouch position. 79
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Spasticity in children and young pe
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Published by the RCOG Press at the
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1 Guideline summary 1.1 Guideline d
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Principles of care Delivering care
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Orthoses General principles Conside
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Botulinum toxin type A General prin
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Intrathecal baclofen General princi
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Orthopaedic surgery Consider orthop
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Guideline summary Number Recommenda
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Oral drugs Number Recommendation 64
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Botulinum toxin No related NICE gui
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Botulinum toxin Number of studies N
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Botulinum toxin L Mean change from
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Botulinum toxin Table 7.6 Evidence
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Botulinum toxin Excessive weakness
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Botulinum toxin The study also repo
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Botulinum toxin * Calculated by the
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Botulinum toxin and young people wh
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Botulinum toxin BoNT-A and physical
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Botulinum toxin treatment of the lo
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Botulinum toxin Chapter 11). The GD
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Botulinum toxin reported PEDI score
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Botulinum toxin drug is injected in
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Botulinum toxin treatment and, ther
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Botulinum toxin Aminoglycosides The
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Botulinum toxin Number Recommendati
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8 Intrathecal baclofen Introduction
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Intrathecal baclofen e When receivi
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Intrathecal baclofen b Mean 0.9 SD
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Intrathecal baclofen d During the t
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Intrathecal baclofen Table 8.10 Evi
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Intrathecal baclofen Number of stud
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Intrathecal baclofen M Baseline med
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Intrathecal baclofen Table 8.18 Evi
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Intrathecal baclofen have CITB repo
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Intrathecal baclofen series (a foll
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Intrathecal baclofen months in chil
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Intrathecal baclofen effectiveness
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Intrathecal baclofen person and in
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Intrathecal baclofen reported impro
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Intrathecal baclofen dangerous to s
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Intrathecal baclofen Number Recomme
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Intrathecal baclofen Number Researc
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Orthopaedic surgery and the natural
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Orthopaedic surgery Table 9.3 Evide
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Orthopaedic surgery Number of studi
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Orthopaedic surgery Number of studi
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Orthopaedic surgery with no change
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Orthopaedic surgery Despite the lac
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Orthopaedic surgery effective commu
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Orthopaedic surgery or bilateral sp
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10 Selective dorsal rhizotomy Intro
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Selective dorsal rhizotomy Three pa
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Selective dorsal rhizotomy (Steinbo
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Selective dorsal rhizotomy Number o
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Selective dorsal rhizotomy Optimisa
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Selective dorsal rhizotomy Motor Fu
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Selective dorsal rhizotomy Optimisa
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Selective dorsal rhizotomy y Mean c
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Selective dorsal rhizotomy reported
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Selective dorsal rhizotomy scores a
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Selective dorsal rhizotomy determin
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Selective dorsal rhizotomy Other co
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Selective dorsal rhizotomy as walki
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Selective dorsal rhizotomy to be ab
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Selective dorsal rhizotomy Number R
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Health economics quantify the benef
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Health economics 11.3 Orthoses Heal
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Health economics The assessment inc
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Health economics If two follow-up a
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Health economics The proportion of
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Health economics • ITB testing an
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Health economics Table 11.11 Costs
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Health economics testing first usin
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Health economics 11.6 Orthopaedic s
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Health economics multidisciplinary
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Health economics designed to benefi
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References Denhoff 1975 Denhoff,E.,
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References Krach 2004 Krach,L.E., K
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References Rice 2009 Rice,J., Waugh
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13 Abbreviations and glossary 13.1
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Abbreviations and glossary PSSRU QA
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Abbreviations and glossary Focal sp
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Abbreviations and glossary Passive
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National Collaborating Centre for Women's and Children's Health

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