R E S E A R C H R E P O R T

The Effect of Ankle-Foot Orthoses

on Community-Based Walking in
Cerebral Palsy: A Clinical Pilot Study
Kristie Bjornson, PT, PhD; Chuan Zhou, PhD; Stefania Fatone, PhD, BPO (Hons); Michael Orendurff, PhD;
Richard Stevenson, MD; Sariya Rashid, MS
Seattle Children’s Research Institute (Drs Bjornson and Zhou and Ms Rashid), University of Washington, Seattle,
Washington; Northwestern Prosthetics Research Laboratory and Rehabilitation Engineering Research Program and
Physical Medicine and Rehabilitation Department (Dr Fatone), Feinberg School of Medicine, Northwestern University,
Chicago, Illinois; Orthocare Innovations (Dr Orendurff), Mountlake Terrace, Washington; Division of Developmental
and Behavioral Pediatrics (Dr Stevenson), Department of Pediatrics, University of Virginia, Charlottesville, Virginia.

Purpose: To examine the effect of ankle-foot orthoses (AFO) on walking activity in children with cerebral
palsy (CP). Methods: We used a randomized cross-over design with 11 children with bilateral CP, mean age
4.3 years. Subjects were randomized to current AFO-ON or AFO-OFF for 2 weeks and then crossed over.
Walking activity (average total steps/day), intensity, and stride rate curves were collected via an ankle ac-
celerometer. Group effects were examined with the Wilcoxon signed-rank test and within-subject effects
examined for more than 1 standard deviation change. Results: No significant group difference was found
in average total daily step count between treatment conditions (P = .48). For the AFO-ON condition, 2 sub-
jects (18%) increased total steps/day; 4 (36%) increased walking time; 2 (18%) had more strides at a rate
of more than 30 strides/min; and 2 (18%) reached higher peak intensity. Conclusions: Clinically prescribed
AFO/footwear did not consistently enhance walking activity levels or intensity. Larger studies are warranted.
(Pediatr Phys Ther 2016;28:179–186) Key words: ambulation, ankle-foot orthoses, cerebral palsy, child, gait

BACKGROUND CP: (1) to correct and/or prevent deformity, (2) to provide

Ankle-foot orthoses (AFO) are an essential rehabili- a base of support, (3) to facilitate training of motor skills,
tation strategy employed to enhance the walking limita- and (4) to improve efficiency of walking.2
tions seen in children with cerebral palsy (CP) who are A literature review revealed some low-level evidence
ambulatory.1 A consensus conference of the International that AFOs enhance walking activity through a combina-
Society for Prosthetics and Orthotics identified the aims tion of biomechanical and physiological mechanisms.2 The
of lower extremity orthotic management in children with solid AFO (SAFO) specifically limits dynamic ankle equi-
nus and midfoot pronation allowing for foot flat contact
with the surface during the stance phase of gait. This in-
0898-5669/110/2802-0179
creased base of support (foot flat vs forefoot/toe contact
Pediatric Physical Therapy during the stance phase of gait) improves balance and sta-
Copyright  C 2016 Wolters Kluwer Health, Inc. and Section on
bility as the tibia and body move over the foot during mid-
Pediatrics of the American Physical Therapy Association
stance of each step. Preventing dynamic equinus (plantar
flexion) has been shown to facilitate ground clearance of
Correspondence: Kristie Bjornson, PT, PhD, Seattle Children’s Research
Institute, 2001 8th Ave # 629, Seattle, WA 98121 (kristie.bjornson@ the swing foot, increase step length and walking speed,
seattlechildrens.org). improve stability during stance phase, and pre-position
Grant Support: This work was supported by funding from NIH K23 the foot in terminal swing phase.2 Various AFO designs
HD060764. have been documented to improve stride length, walking
Michael Orendurff is an employee of Orthocare Innovations, a former speed, single-limb stance, dorsiflexion at heel strike, and
manufacturer of the StepWatch monitor used in this study. No other
authors have conflicts of interest. ankle moment at push-off; reduce equinus posturing and
DOI: 10.1097/PEP.0000000000000242 ankle excursion during loading; and enhance ankle power
at push-off in children with CP.2

Pediatric Physical Therapy Effect of Ankle-Foot Orthoses 179

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 Clinically, lower extremity impairments (passive ing computerized 3-dimensional gait analysis, gross mo-
range of motion, segment alignment) and gait patterns tor function tests, energy cost, and clinical gait analysis.
(kinematics) are examined in the process of orthotic pre- To date, activity “performance” (what a child does in the
scription, but are not consistently identified and/or agreed day-to-day environment according to the ICF) has not
upon in the literature. The goal of each AFO prescribed been reported.13 Hence, the aim of this pilot study was
for a child with CP is the collective improvement of these to examine the effect of AFOs on walking activity within
biomechanical variables to increase the ease of taking an community-based settings in children with CP.
individual step, with the potential to enhance walking
activity and functional skills. For example, Buckon and
colleagues3 documented normalized ankle kinematics, im- METHODS
proved stride length and walk/run/jump skills with either This study was a prospective randomized cross-over
the posterior leaf spring or hinged AFO as compared with design with a convenience sample of 11 participants. With
a rigid or SAFO in children with CP who are ambulatory. prior approval from the human subjects review committee,
Physiologically, we know that children with CP a focused mailing was addressed to potential participants
expend more energy to walk than children who are from a specialty care pediatric facility in the US Pacific
typically developing (TD), and that energy cost increases northwest and local therapy providers. Children having a
as functional level decreases.4 Recently, lower physical diagnosis code of ambulatory CP and ages 2 to less than
activity levels were also found to be associated with higher 10 years made up the initial mailing list. This list was fur-
oxygen cost of walking in 10 children with CP who ther screened before mailing to confirm ambulatory status
were ambulatory.5 However, Maltais et al6 reported lower and use of English as the primary language.
oxygen cost for walking in children with spastic CP while After obtaining informed consent and assent, as ap-
wearing a hinged AFO with no effect on standing and propriate, participants were enrolled who met the addi-
walking/running/jumping skills. Thus, AFO use might tional inclusion criteria of (1) Gross Motor Function Clas-
affect walking activity levels by decreasing the oxygen sification System (GMFCS) levels I to III, (2) bilateral CP,
cost of walking. (3) wearing bilateral AFOs more than 8 hours per day
The use of AFOs has developmental and psychosocial for more than 1 month, (4) the primary goal of current
implications for children with CP and their families. Chil- AFOs was to facilitate balance and walking, and (5) the
dren with physical disabilities are at risk for delayed social family was willing to discontinue AFO use for 2 weeks.
development.7,8 Facilitation of an upright posture posi- Exclusion criteria included having visual impairment that
tively supports acquisition of cognitive, visual perceptual, limited physical activity, lower extremity injection therapy
play, and social interaction skills, as well as walking inde- in the past 3 months, medication changes planned during
pendence. Naslund et al9 described parental perceptions the study period, an uncontrolled seizure disorder that
of the use of dynamic ankle-foot orthoses (DAFO) us- affected mobility skills, neurosurgical or orthopedic surg-
ing structured parental interviews. Parents noted positive eries in the past 6 months, or other surgeries or procedures
functional effects of the DAFO for foot support, balance, in the past 2 weeks.
standing, and sitting posture as well as overall physical ac- At a center-based baseline study visit, demographics,
tivity. Parents also reported foot pain with new orthoses current AFO prescription, and shoe design were docu-
and the need to change socks often because of excessive mented (Table 1). Participants then underwent a sagittal
sweating when wearing plastic orthoses.9 Finding shoes plane video vector gait analysis (Contemplas Motion Anal-
that fit over the AFO was also a problem. Some parents ysis, Templo Version 7, zFlo Motion Analysis Systems,
noted that the DAFO seemed to make younger, smaller Inc, Boston, Massachusetts) with shoes only, and shoes
children more clumsy, as they got in the way of floor play.9 with current AFOs. Footwear shoe profiles were similar
Having to don and doff orthoses was noted as a burden of between conditions but were not the same shoe because of
care. size differences. After these assessments were completed,
Orthotic intervention has large economic implica- the subject was assigned to an initial intervention wear
tions for children with CP and their families and insur- phase (currently prescribed AFO-ON/footwear or AFO-
ers. Given that approximately 53 000 AFOs are fabricated OFF/footwear) by opening a sealed opaque randomization
each year in the United States at an average Medicare re- envelope. After the child was assigned to an intervention
imbursement of $417, more than $2.2 million per year is wear phase, the StepWatch (SW) multiaxis accelerometer
spent on them.10,11 Further potential orthotic costs range (Orthocare Innovations, Mount Lake Terrace, Washing-
from $6400 to $15 400 for casting and fabrication (de- ton) was fitted to the lateral side of the left ankle in a
pending on speed of growth) for children from 2 to 9 years knit cuff (either with or without the AFO per random-
old. ization) and calibrated to the child’s walking pattern per
The literature examining the effect of orthoses on manufacturer guidelines by adjusting sensitivity and ca-
walking in children with CP has focused primarily on mea- dence settings to suit individual walking patterns in each
sures of activity “capacity” (defined by the International condition (AFO-ON or AFO-OFF). Calibration of the SW
Classification of Functioning and Disability [ICF] as what accelerometer is essential to accurately document differ-
a child can do in a laboratory/clinic environment)12 us- ences in walking activity levels between conditions for

180 Bjornson et al Pediatric Physical Therapy

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 TABLE 1
Subject and Intervention Characteristics

Midstance SVA Midstance SVA

AFO-OFF/ AFO-ON/
Gait Footweara Footweara
Subject Age, y GMFCS Pattern14 Bilateral Orthosis Design Shoe Profile (Right/Left) (Right/Left)

1 5.0 II True equinus Nonarticulated AFO Negative heel, −4/−2◦ 3◦ /5◦

0◦ PF stop, free DF round sole
Flexible toe plate
2 6.0 II Crouch Hinged AFO Negative heel, 20◦ /28◦ 20◦ /22◦
0◦ PF stop, 15◦ DF round sole
Flexible toe plate
3 3.0 I True equinus Solid AFO (SAFO) Negative heel,b −5◦ /−2◦ 8◦ /10◦
Angle of ankle in AFO −5◦ round sole
Solid foot plate
4 4.0 II True equinus Nonarticulated AFO Negative heel, 0◦ /0◦ 5◦ /4◦
0◦ PF stop, free DF round sole
Flexible toe plate
5 3.8 III True equinus Nonarticulated AFO Negative heel, −3◦ /−3◦ 3◦ /5◦
0◦ PF stop, free DF round sole
Flexible toe plate
6 5.2 II Jump Hinged AFO Negative heel, 28◦ /18◦ 28◦ /24◦
0◦ PF stop, 15◦ DF round sole
Flexible toe plate
7 3.8 II Crouch Solid AFO (SAFO) Negative heel, 15◦ /20◦ 12◦ /20◦
Angle of ankle in AFO 0◦ round sole
Flexible Toe plate
8 3.2 II True equinus Solid AFO (SAFO) Negative heel, −3◦ /−3◦ −3◦ /4◦
Angle of ankle in AFO 0◦ round sole
Flexible toe plate
9 5.8 II Jump Supramalleolar orthosis Negative heel, 12◦ /8◦ 10◦ /8◦
Flexible toe plate round sole
10 4.3 II Crouch Hinged AFO Negative heel, 32◦ /15◦ 15/◦ 13◦
0◦ degrees PF stop, 15◦ DF round sole
Flexible toe plate
11 3.6 II Jump gait Solid AFO (SAFO) Flat sole,b 15◦ /20◦ 9◦ /9◦
Angle of ankle in AFO −5◦ point loading
Solid foot plate rocker

Abbreviations: AFO, ankle-foot orthosis; DF, dorsiflexion; GMFCS, Gross Motor Function Classification System; PF, plantar flexion; SVA, shank-to-
vertical angle.
a Positive number in degrees from vertical = inclined shank, negative number in degrees from vertical = reclined shank.
b SVA optimized.15

each child. Participants were instructed to wear the SW

all their waking hours for 14 days except when bathing or
swimming. A home visit by the primary author was then
carried out wherein the SW data were downloaded to a
laptop computer. Participants then changed to the oppo-
site intervention wear phase, and the SW recalibrated to
the walking pattern of the new condition. Participants then
wore the SW for 14 days and returned the monitor and cuff
to study staff via postage-paid envelope.
Functional gross motor level was documented using
the GMFCS16 (Table 1). Sagittal plane barefoot video from
the baseline visit was viewed to classify type of gait pat-
tern according to the criteria described by Rodda et al14
(eg, jump, equinus, or crouch) by observation of shoes-
only gait at midstance. Video vector gait analysis was Fig. 1. Shank to vertical angle at midstance phase of gait.
used to assess the influence of the AFO and footwear on
lower extremity alignment.17 A still picture of midstance Interrater reliability (percentage of absolute agreement) of
was printed from the sagittal video and bilateral shank- SVA measures between the primary author and a research
to-vertical angles (SVAs) manually measured (Figure 1). assistant was 95% across 66 pictures.

Pediatric Physical Therapy Effect of Ankle-Foot Orthoses 181

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 Community-based walking activity was examined (plantar flexion) to 0◦ (neutral/plantigrade), nonarticu-
with the SW. The SW is designed to record steps in each lated AFOs with plantar flexion (PF) stop at neutral (ie,
time interval by identifying the magnitude and timing of 90◦ ) and free dorsiflexion (DF) (n = 3), hinged AFOs with
multiaxial accelerations that occur with each step, usu- a range of 0◦ PF to 15◦ DF (n = 3), and supramalleolar
ally foot-off, but sometimes other gait events. Accuracy orthoses (n = 1). All participants wore tennis shoes with
of calibration to individual walking patterns and treatment round soles and negative heels, except 1 who had a flat
conditions was checked against visual observation of stride sole and point loading rocker at approximately 85% of
counts during a more than 100-stride walking trial wearing shoe length (S11).
the SW. Strides were manually counted with a handheld Two participants (S3, S11) had wedging of the sole
counter and compared with the SW recording of strides. of their shoes to optimize the SVA during static standing
A ratio of agreement was taken and averaged. Accuracy and midstance per their clinical orthotist/therapist pre-
with respect to manual counts and comparison to other pe- scription. On the basis of a published orthotic manage-
dometers confirms the accuracy and precision of the SW for ment algorithm, an optimized SVA during static standing
detecting strides taken.18 The primary outcome of walking and midstance of walking is when the shank is inclined
activity level was summarized through average total strides to allow the knee to be over the toes and thigh vertical.15
per day. Secondary outcomes were percent daytime hours For the AFO-OFF condition, midstance SVAs ranged from
walking and walking intensity captured by the number of −5◦ (reclined) to 32◦ (inclined) across all limbs (Table 1).
strides taken at a rate greater than 30 strides/min, peak Calibration accuracy of SW stride count to manual stride
activity index (the average of the top 30 one-minute stride count averaged 100% (range 94-108) across all treatment
counts/day), and stride activity curves.19 conditions.
Participants were randomized to start with or without No significant difference was found in the primary
the AFO, (AFO-ON or AFO-OFF [with footwear only], outcome of average daily total step count between AFO-ON
respectively) for 2 weeks, and then switch to the opposite and AFO-OFF (P = .48). The between-treatment condition
condition for another 2 weeks. Participants wore the SW comparison of the secondary outcomes, percentage of time
during the entire 4-week study period; therefore, each par- walking each day, average number of strides each day more
ticipant contributed 2 weeks of SW data to the AFO-ON than 30 strides/min, peak activity index, and stride rate
condition and 2 weeks of SW data to the AFO-OFF con- curves showed no significant differences (P = .33-0.79,
dition. Consistent with published SW monitoring proto- Table 2 and Figure 2).
cols for children,19-22 5 days (4-week days and 1 weekend Within subject comparison using the criterion of
day) from the second week of monitoring were selected greater than 1 standard deviation change from AFO-OFF
for analysis of walking activity variables.22 StepWatch data condition identified 2 children (18%) who took a greater
were considered valid for analysis if less than 3 hours of number of steps/day with AFO-OFF (S4 and S10) and
inadequate monitoring were found (eg, monitor worn up- 2 (18%) who did better with AFO-ON (S3 and S11,
side down) or no stride counts that were unexplained (eg, Figure 3A). For percent time walking each day, 4 (36%)
bathing) during daytime hours (6:00 am to 10:00 pm). All participants walked more each day with AFO-ON (S1, S3,
participants maintained their typical daily activities for the S8, and S11) and 1 (9%) walked more with AFO-OFF
4 weeks of monitoring (ie, school was in session). (S10, Figure 3B). Numbers of strides/day more than 30
Demographics and clinical impairments were re- strides/min and peak activity index were greater during
ported descriptively. Because of the small sample size and the AFO-ON condition for 2 participants (S3 and S11) and
paired nature of outcomes, between-treatment group con- less for 1 (S2, Figure 3C/D). Only 2 subjects (S3 and S11)
dition (AFO-ON vs AFO-OFF) effects were examined with increased both walking activity level (number steps/day,
the nonparametric Wilcoxon signed-rank test for paired
data (α set at 0.05). To capture individual effects, between-
treatment condition data were plotted and examined for TABLE 2
greater than 1 standard deviation change from the AFO- Average (1 SD) of StepWatch Variables by Intervention Condition
OFF condition, on the basis of the hypothesis that the
StepWatch Variables AFO-ON AFO-OFF P Valuea
current AFO prescription would positively enhance com-
munity walking. Primary outcome: 4660 (1421) 4897 (1438) .48
average total
strides/day
RESULTS Secondary outcomes
Percent daytime 0.49 (0.07) 0.46 (0.08) .33
Eleven participants (S1-S11) were enrolled and hours walking
completed the protocol. Average age was 4.3 years (range Average number of 1918 (1025) 1986 (1075) .66
3.0-6.0 years, Table 1). These children were classified as strides >30
strides/min
GMFCS levels I (n = 1), II (n = 9), and III (n = 1), with gait
Peak activity index 43.6 (6.5) 44.1 (7.4) .79
patterns characterized as equinus (n = 5), jump (n = 3),
and crouch (n = 3). Current orthoses included SAFOs Abbreviation: AFO, ankle-foot orthosis.
(n = 4) with the ankle angle in the AFO ranging from −5◦ a Paired Wilcoxon signed-rank test.

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Fig. 2. Walking stride rate curves for AFO-ON and AFO-OFF conditions (n = 11). These curves are the mean group trajectory of minutes
spent at increased stride rates (solid and open circles) and 95% confidence interval (vertical lines).

percent time walking) and intensity (number of strides/day and moderate rates (30-60 strides/min), whereas the day-
>30 strides/min, peak activity index) with AFO-ON. to-day walking of youth with CP is predominately at low
rates.21 Recent work has documented a positive association
between daily walking levels and intensity with mobility-
DISCUSSION based participation in daily life for youth with CP.21,23
We did not find consistently favorable community- Also, from a public health perspective, youth with CP
based walking activity outcomes for the AFO-ON regardless of GMFCS level demonstrate maximal walk-
condition compared with the AFO-OFF condition. ing activity levels that are far below those recommended
The within-subject analysis showed large variability in for overall health (60 min/day of moderately vigorous
outcomes between the 2 conditions. This variability may activity).21,24
be a function of a general lack of consistency in orthotic The orthoses worn by the children in this study were
prescription on the basis of gait pattern and biomechanical not in accord with previously published algorithms match-
impairments. This includes multiple orthoses employed ing orthoses to gait pattern.14 Our data suggest that several
for the same gait pattern, heterogeneity of the study subjects were currently wearing prescriptions that did not
sample, and/or the general population of children with CP address the segmental biomechanical limitations of their
that are ambulatory, and the lack of individualization of presenting gait pattern (S2, S6, S9, and S10). For example,
shoes and SVAs. The results of this pilot study suggest that subjects 2 and 10 with crouch gait patterns were wearing
the majority of participants were not currently wearing hinged AFOs that would be unable to limit excessive tib-
orthoses and/or footwear prescriptions that positively in- ial progression during stance. A child with a crouch gait
fluenced their daily walking activity levels or the secondary pattern, per published algorithms, should be prescribed a
outcomes of walking intensity. The 2 subjects for whom device that limits shank inclination during midstance (eg,
the SVA was explicitly optimized (1 with a shoe modified to a SAFO). Assuming that the remaining subjects (S1, S3,
have a point loading rocker) demonstrated a positive effect S4, S5, S7, S8, and S11) were wearing orthoses that had
of AFO/footwear use on daily walking levels. This positive potential to address their individual gait impairments, only
effect was also documented for the secondary outcomes of 2 participants (S3 and S11) had a greater than 1 standard
walking time and walking intensity for these 2 subjects. deviation change in walking activity levels and intensity
AFO management in CP must positively influence during the AFO-ON versus the AFO-OFF condition.
day-to-day walking activity. As compared with children Numerous authors have proposed theoretical guide-
who are TD, youth with CP take significantly fewer strides lines for the optimal SVA for standing and walking in
each day and spend less time walking.21 Relative to inten- SAFOs.25-27 These proposed recommendations range from
sity or patterns of walking, youth that are TD spend a simi- “slight incline” and “knee cap over metatarsophalangeal
lar number of strides and/or time at low (1-30 strides/min) joints” to specific ranges (eg, 7◦ -10◦ incline). In 1972,

Pediatric Physical Therapy Effect of Ankle-Foot Orthoses 183

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Fig. 3. StepWatch walking activity data comparing AFO-ON and AFO-OFF. (A) Average daily total steps count. (B) Percentage of active
time walking. (C) Average number of strides more than 30 strides/min. (D) Peak activity index. Red arrows indicate greater than 1
standard deviation improvement with AFO-ON. Yellow arrows indicate greater than 1 standard deviation improvement with AFO-OFF.
Red circled data indicate participants with shank to vertical angle addressed in prescription. One standard deviation of change is based
on the group AFO-OFF condition.

Glancy and Lindseth,28 on the basis of visual gait analy- tional outcomes of an individualized prescription. If future
sis, proposed 3◦ to 5◦ of incline. In 1992, Hullin et al29 work confirms the influence of footwear on walking out-
proposed 0◦ with a rocker sole and 10◦ incline without a comes, fiscal and policy implications will follow because
rocker sole. Owen reported SVA tuned to optimum align- footwear is not traditionally reimbursed in some countries
ment using a video vector analysis of approximately 7◦ to (eg, the United States).
15◦ (mean 11.4◦ ).30 Most recently, Jagadamma et al31,32 Study limitations should guide the interpretation of
proposed an average SVA of 10.8◦ incline on the basis of these pilot data. First, the sample size was small and maybe
gait analysis in youth with CP. The individual SVA data under powered to find true differences between treatment
for the 4 subjects in this study wearing SAFOs (S3, S7, S8, conditions. Although the randomized cross-over design
and S11) were broader than the values reported in the lit- does somewhat mitigate this issue, a larger sample size
erature, which may have contributed to our observation of is needed to corroborate these findings. Clinical hetero-
an inconsistent positive group effect on walking activity. geneity of this study sample and the broader population
These results support the need for further research of children with CP who are ambulatory could confound
on the effect of AFO/footwear prescription relative to the the effect of AFO use on walking activity outcomes. More
gait pattern and physical and neuromotor impairments of work is needed to understand the influence of the SVA
each limb for each client. This concurs with emerging rec- and shoe modifications within orthotic management. Such
ommendations that the SVA needs to be individualized for studies would be enhanced by use of full kinetic and
each leg within each patient depending on their gait pat- kinematic analyses in addition to step activity monitor-
tern and diagnosis.33 Orthotic management also needs to ing. A key strength of this project was that the type of
account for footwear as an influencing factor in the func- monitoring used, which can be feasibly implemented in

184 Bjornson et al Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
clinical practice, allowed walking activity to inform or- 6. Maltais DB, Bar-Or O, Galea VA, Pierrynowski MR. Use of orthoses
thotic management. In contrast to much of the literature, lowers the O2 cost of walking in children with spastic cerebral palsy.
Med Sci. 2001;33(2):320-325.
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CLINICAL BOTTOM LINE

Commentary on “The Effect of Ankle-Foot Orthoses on Community-Based Walking in Cerebral Palsy: A
Clinical Pilot Study”

“How could I apply this information?”

Ankle foot orthoses (AFOs) are commonly prescribed to improve walking in children with cerebral palsy. Yet,
the results of this study did not consistently support this result. Although there were many variables that likely
affected the results, this study raises an important question: Does bracing alone increase a child’s walking activity
level in the community? There appears to be a need for the clinical team composed of the patient, family, orthotist,
therapist, and physician to assess each child’s prescribed brace more closely, monitor it regularly, and investigate
whether or not it provides a functional benefit. The ankle accelerometer used in this study may accurately track an
individual’s walking activity at home and in the community; however, the cost may be prohibitive. A pedometer
or fitness tracker can be a cost-effective alternative.
Parent comments: I was not surprised that the subjects had different results because of the many differences in
each subject’s environment. In order for research to be more accurate, the subjects would need to be tested in the
same environment, performing the same activities for the same amount of time. The results of this study were
inconclusive so they do not help me to decide whether or not I want my daughter to continue wearing AFOs. Also,
the results will not affect my daughter’s physical therapy because her treatment sessions focus on strengthening
her muscles without the braces.
“What should I be mindful about when applying this information?”
It should not be assumed that AFOs or footwear alone enhances walking activity. The bracing variations among
subjects made it difficult to determine which brace features improve the patient’s function. An optimized shank
to vertical angle (SVA) is another feature for the clinical team to consider when recommending a brace because
SVA may contribute to gains in ambulation activity. Further studies are needed to identify the key components for
optimal bracing and footwear, in order to guide orthotic prescription and maximize functional walking activity.
Parent comments: In my experience, the pros of AFOs are that they provide support and promote longer walking
times. The cons are that they are too bulky. The bulkiness has caused my daughter to fall more often than usual.
We also need to buy shoes that are 2 sizes bigger than her feet. From a social perspective, my daughter has been
teased and bullied because of the way she walks when wearing AFOs. But in response, she has educated students
about her medical condition.

Sharon Gonzalez, PT, DPT

California Children’s Services, County of Los Angeles
Glendale, California
Eunice Shen, PT, PhD, DPT, PCS
California Children’s Services, County of Los Angeles
El Monte, California
Florin Taylor
Mother of a girl with cerebral palsy
Burbank, California
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000262

186 Bjornson et al Pediatric Physical Therapy

Copyright © 2016 Wolters Kluwer Health, Inc. and the Section on Pediatrics of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.