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REHAB-1091; No. of Pages 10

Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx

Available online at

ScienceDirect
www.sciencedirect.com

Review

Efcacy of ankle foot orthoses types on walking in children with

cerebral palsy: A systematic review
Atefeh Aboutorabi a,b, Mokhtar Arazpour a,b,*, Monireh Ahmadi Bani b, Hassan Saeedi c,
John S. Head d
a
Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
b
Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran
c
Department of Orthotics and Prosthetics, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran
d
Institute for Health & Social Care Research (IHSCR), Faculty of Health & Social Care, University of Salford, Salford, UK

A R T I C L E I N F O A B S T R A C T

Article history: Background: Ankle foot orthoses (AFOs) are orthotic devices that can be used to normalize the walking
Received 31 January 2017 pattern of children with cerebral palsy (CP). One of the aims of orthotic management is to produce a more
Accepted 27 May 2017 normal gait pattern by positioning joints in the proper position to reduce pathological reex or spasticity.
Objective: To conduct a systematic review of the literature and establish the effect of treatment with
Keywords: various types of AFOs on gait patterns of children with CP.
Ankle foot orthoses Methods: PubMed, Scopus, ISI Web of knowledge, Cochrane Library, EMBASE and Google Scholar were
Orthosis
searched for articles published between 2007 and 2015 of studies of children with CP wearing the
AFO
Gait
following AFOs: hinged (HAFO), solid (SAFO), oor reaction (FRO), posterior leaf spring (PLS) and
Children with cerebral palsy dynamic (DAFO). Studies that combined treatment options were excluded. Outcomes investigated were
CP 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 specic 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.
C 2017 Elsevier Masson SAS. All rights reserved.

1. Introduction society [1]. Orthotic management is a signicant and useful

Efcient and effective walking is an important treatment goal
for children with cerebral palsy (CP) because mobility is associated
with functional independence and participation of the child in
* Corresponding author. Department of Orthotics and Prosthetics, University of
Social Welfare and Rehabilitation Science, Kodakyar st., Daneshjo Blvd., Evin,
Tehran, 1985713834, Iran. Fax: +98 21 22 18 00 49.
E-mail address: m.arazpour@yahoo.com (M. Arazpour).
treatment option for a number of conditions that affect gait and
posture and usually forms part of an overall rehabilitation program
established for patients with CP. To improve gait parameters and
normalize movement patterns with spastic CP, a variety of orthotic
devices are used [2]. In children with CP, the aim of orthotic
management in the form of ankle foot orthoses (AFOs) is to
produce a more normal gait pattern by positioning peripheral
joints in a way that reduces pathological reex patterns or by
blocking pathological movement of the joints [2]. A wide variety of

http://dx.doi.org/10.1016/j.rehab.2017.05.004
1877-0657/ C 2017 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004
G Model
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2 A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx
AFOs are used in clinical practice; they are characterized by their
design and their constituent materials, enabling different levels of
stiffness and ankle control. The most frequently prescribed are the
solid AFO (SAFO), dynamic AFO (DAFO), oor reaction orthosis
(FRO), posterior leaf spring (PLS) or hinged AFO (HAFO) with a
plantarexion limitation facility.
AFOs are designed to improve the efciency of gait of children
with CP [3] and provide a positive effect on gait kinetics and
kinematics [4,5] as well as decrease the energy expenditure of
walking [68] and enhance the attainment of functional skills
[6]. These positive effects on gait include increased active ankle
range of motion (ROM) [9,10] and maximum knee extension [11],
stride length and walking speed [9,12]. However, a previous
literature review [13] reported that the quality of the studies was
too low to accurately determine the efcacy of AFOs on gait of
children with CP.
The aim of this study was to conduct a systematic review of the
recent literature to determine the effect of different AFO types on
the gait parameters of children with CP. We aimed to determine
whether AFOs have a positive effect on the gait parameters of
children with CP and whether these results are supported by high-
quality studies.
2. Methodology
2.1. Eligibility criteria
Articles were selected by using the Preferred Reporting Items
for Systematic reviews and Meta-analyses (PRISMA) method
[14]. Inclusion criteria were studies that evaluated the effect of
any type of AFO on the gait of children with CP. Exclusion criteria
were studies that did not examine AFOs as a therapeutic
intervention or examined other types of treatment such as foot
orthoses, robotic-assisted training botulinum toxin, functional
electrical stimulation or surgery in conjunction with AFOs. Only
outcome measures related to gait and functional ability were
considered in this review.
2.2. Information sources
We searched for articles published from 2007 to 2015 in the
databases PubMed, Scopus, ISI Web of Knowledge, Cochrane
Library, EMBASE and Google Scholar and also ClinicalTrials.gov for
nding randomized controlled trial (RCT) study designs. The
review strategy involved checking the title and abstracts of articles
for the inclusion criteria. Abstract-only reports were not consid-
ered because of limited information to determine the specic
quality of the studies.
2.3. Search strategy
The search strategy was based on the population intervention
comparison outcome (PICO) method with selected keywords
joined by the words OR, AND and NOT. The keywords, from
the MeSH database in MEDLINE were ankle foot orthoses, AFO, gait,
children, CP, cerebral palsy and walking. For the keyword orthoses,
a truncation of the root orth (e.g., orthosis, orthoses, orthotic
devices) was also used. The date of the last search was January 29,
2016.
2.4. Study selection
Studies with the following in the title or abstract were eligible:
(1) participants were children with CP, (2) the intervention
included AFOs, (3) the outcome measures included gait param-
eters, and (4) statistical analyses were reported. The full text of all
Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004
studies was obtained; the studies are checked more than once
against the inclusion criteria, and then assessed for methodological
quality. Study designs included RCTs, prospective and retrospec-
tive studies that included within- and/or between-group compa-
risons or cross-sectional studies. Titles and/or abstracts of studies
were retrieved, then the full text of studies that met the criteria
were independently assessed by 2 review team members.
2.5. Assessing risk of bias in included studies
The quality of studies was assessed by using the Physiotherapy
Evidence Database (PEDro) scale [15], with the level of evidence for
each selected study assessed according to the criteria suggested by
Law and Philp [16], which limited the impact of bias in this process.
High scores represented high quality, and this process was
conducted independently by 2 reviewers.
2.6. Data collection and synthesis
Collated data included general information such as author
name(s), date of publication, subject demographics, study design,
intervention characteristics, outcome measures and key results.
Key outcomes were described in accordance with the International
Classication of Functioning, Children and Youth version (ICF-CY)
[17]. The review ndings were synthesized qualitatively by
methodological (study design, outcomes) and clinical (participant
and intervention characteristics) heterogeneity. The individual P-
values for accepted signicance levels in studies are shown in
Table 2.
3. Results
3.1. Study selection
We initially identied 62 studies and excluded 25 on the basis
of their title and keywords. A further screening to evaluate the
relevance of the abstract and the aim of each study excluded
23 further studies. In total, 17 studies met our inclusion criteria
(Fig. 1).
Four studies involved RCTs or controlled clinical trials and had
level II evidence [1821]. The remainder had a cross-sectional
design with within- and/or between-group comparisons. The
PEDro scoring details and level of evidence of included studies are
in Table 1.
3.2. Study characteristics
3.2.1. Characteristics of participants
A total of 1139 participants were examined in the selected
studies: 893 with spastic diplegia, 128 spastic hemiplegia, 7 spastic
triplegia, 59 quadriplegia, and 9 a mixed type. One child had
athetoid CP and 4 children had dyskinesia. The studies included
38 healthy controls. The mean sample size was 66 (range 10378)
with mean age 7.58 years (range 118) (Table 2).
3.2.2. Types of interventions
Because of the different terms used to describe the same type of
AFOs and other descriptors, summarizing results was difcult.
Therefore, we used the following terminology dened by Alexan-
der and Xing to dene the AFO types [22]; solid AFO (SAFO) refers
to solid polyethylene AFO (PAFO) or metallic AFO [5], rigid AFO
[4,10], xed AFO [23], or solid AFO [7,12,19,24,25]. Hinged AFO
(HAFO) refers to hinged AFO [8,12,19,20,24,26] or articulated AFO
[5,10]. Posterior leaf spring AFO (PLS) refers to posterior leaf spring
and spring-type AFO [7,9,24]. Dynamic AFO (DAFO) refers to DAFO
[21]. Floor reaction AFO (FRO) refers to FRO [11,27] or ground
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A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx 3

Records idened by datbase

searching (PubMed, Scopus, ISI Records idened by other
Web of Knowledge) means
(n = 58) (n =16)

Records aer duplicates

Records excluded
removed
(n =25)
(n = 62)

Full-text arcles
Title and abstract excluded (n = 23)
screened (n= 37) Because of
- Intervenon (n=9)
- Populaon (n=2)
-Study design (n=8)
Full-text arcles assessed -not relevant outcome
for eligibility (n=14) measures (n=4)

Added studies aer hand

searching (n= 3)

Studies included in
qualitave synthesis
(n =17)

Fig. 1. Flow of study selection.

reaction AFO [5,18]. The term Orteams [9] and carbon ber spring
AFO (CFO) [9] were not included in these terminologies.
3.2.3. Type of outcomes
A summary of the results based on the outcomes described in
terms of the ICF-CY recommendations as well as authors results
are presented in Table 2.
3.3. Body function and structure
3.3.1. Temporal-spatial gait characteristics
Step length increased with SAFO as compared with barefoot
walking (P = 0.01) [4], from a mean of 0.82  0.3 m with barefoot to
0.98  0.2 m with SAFO, whereas in healthy children, stride length
was 1.40  0.2 m [4]. With diplegic spastic CP, stride length was
signicantly longer with SAFO, about 13%, 17.4% and 18%, as
compared with barefoot [10,12,28], and with hemiplegic CP, stride
length was increased 11.7% [10]. Cadence increased from
117.7  27 to 122.3  14.7 step/min as compared with barefoot.
Jagadamma et al. suggested improved cadence with SAFO [4], but
Rogozinski et al. reported no change with S/HAFO [10].
With hemiplegic CP, stride length was increased signicantly to
0.830.9 m with HAFO versus barefoot (0.730.76 m) [8,26]. In
another study of diplegic CP, stride length increased 13% with
HAFO (P < 0.005) [12]. Children with hemiplegic and diplegic CP
did not differ in cadence with HAFO versus barefoot [8,10,26]. Use
of HAFO for hemiplegic CP increased single support time and
improved symmetry of gait [8,10,26].
In hemiplegic and diplegic spastic CP, stride length was
increased with PLS (P < 0.05) [9,28] and FRO (approximately 3%
and 16%, P = 0.001) [18,27] versus no AFO. In dipegic CP, cadence
increased signicantly with FRO versus barefoot, from 62.5  4.3 to
73.42  3.8 steps/min [18], but another study found no signicant
difference in cadence with FRO in diplegic CP [27].
Stride length was improved from 0.69  0.21 m with barefoot
walking to 0.790.85 m with DAFO [21]. However, cadence was
decreased signicantly with DAFO (P = 0.001) [21].
3.3.2. Kinematics analysis
Normal knee and hip ROM in healthy children are 61.6  5.6 deg
and 50.9  6.2 deg, respectively, but Jagadamma et al. [4] reported
knee ROM increased to 48.9  14.4 deg and hip ROM to 45.7  6.2 deg
(P = 0.04) with SAFO in children with CP [4]. Hayek et al. found
reduced knee exion at initial contact by 8.5 deg (P = 0.032) with
SAFO versus barefoot in hemiplegic CP, with no difference in diplegic
CP [10]. Peak knee extension in midstance improved (from 20 deg to
10 deg exion) with SAFO (P = 0.014) [23]. For ankle ROM, with
hemiplegic CP, S/HAFO increased dorsiexion 9.413.4 deg at initial
contact (P < 0.001) and signicantly increased dorsiexion 9.9 deg at
swing [10].
AFO signicantly decreased maximum plantarexion during
swing and mean plantarexion during stance in hemiplegic CP
[8,26]. Passive ankle dorsiexion angle was improved with HAFO
in diplegic CP [20]. Knee exion at initial contact was decreased
from 16.58 + 9.33 to 8.48 + 6.65 deg exion as compared with
barefoot (P = 0.02) [8].
Just one study assessed the effect of PLS on kinematics with CP.
As compared with barefoot, PLS decreased maximal knee exion in
swing and knee hyperextension in stance and signicantly
increased hip ROM during the stance phase of gait in hemiplegic
CP [9]. CFO had positive effects during loading response, terminal
stance and maximal hip extension in stance in hemiplegic CP [9].
FRO was effective in restricting sagittal plane ankle motion
during the stance phase of gait in diplegic CP (P < 0.001) [27]. Peak

Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004
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4 A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx

knee extension in midstance was improved meaningfully with FRO

score
Total
in diplegic CP [11,18,27]. It was improved in midstance from

3
5
9
3
3
4
5
7
3
3
3
2
3
2
2
3
3
29  14 to 18  14 deg exion [27]. Lucareli et al. [11] reported no
signicant changes in hip and pelvis kinematics with FRO in diplegic
variability
Point of

CP.
Yes DAFO improved dorsiexion in swing as compared with
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
barefoot (917 deg difference vs barefoot; P  0.01). Dorsiexion
was increased signicantly in stance with DAFO (13 deg difference
statistical
Between-

vs barefoot; P = 0.003) [21]. Knee extension in stance did not differ

analysis
group

between DAFO and barefoot conditions (P = 0.006), but hip

Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes

Yes

Yes
Yes
No

No

No
No

No
No
extension in stance was improved with DAFO versus barefoot
(24 deg difference; P  0.002) [21].
Intention-

analysis
to-treat

3.3.3. Kinetic analysis

Yes

Yes
Peak hip and knee extension/exion moments and also peak
No
No
No
No
No

No
No
No
No

No
No
No
No
No
No
ankle plantar/dorsiexion moments were signicantly higher with
SAFO versus barefoot [4]. SAFO/PLS reduced peak ankle power
follow-up

during the stance phase of gait (1.400.89 W/kg between barefoot

> 85%

and AFO) [7] and HAFO decreased power to 1.61 + 1.17 W/kg
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
versus barefoot (1.96 + 1.25 W/kg) [8]. PLS [7] and also FRO [27]
signicantly improved sagittal knee moment in spastic CP. Van
assessors

Gestel et al. reported signicantly increased hip moment and

Blinded

power with CFO in hemiplegic CP [9]. Push-off power was

Yes

Yes
No
No

No
No
No
No

No
No
No
No
No
No
No
No
No

signicantly reduced with DAFO versus barefoot (0.40.6 W/kg

difference; P  0.03) [21].
therapists
Blinded

3.4. Activity outcomes

Yes
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No

3.4.1. Energy expenditure

The effect of AFO on energy expenditure during gait was
participants

measured by the energy expenditure index (EEI) [5,6], the rate of

Blinded

expired gas for oxygen consumption [7] and an open-circuit

Yes

calorimeter [8].
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No

EEI values were lower with plastic SAFO than metallic AFO
(0.25 vs 0.38 beats/m) [5]. Solid PAFO could be more benecial in
at baseline
prognosis

terms of energy consumption in diplegic CP (P < 0.05) [5]. Howev-

Similar

er, in other studies, energy expenditure remained unchanged with

Yes
Yes
Yes

Yes
Yes
No
No
No

No
No
No
No
No
No
No
No
No

SAFO in diplegic CP [7,12]. Vanwala et al. reported an increase in

energy expenditure with SAFO versus barefoot in diplegic CP
(P < 0.05) [6].
Concealed
allocation

One study reported meaningfully decreased energy expendi-

Level and methodological quality of the evidence for studies in the systematic review.

Yes

Yes

ture with than without HAFO in hemiplegic CP (8.81 + 1.68 vs

No
No

No
No
No
No

No
No
No
No
No
No
No
No
No

9.50 + 1.83 mL/kg/min) [8]. Brehm et al. reported signicantly

improved cost of walking with PLS versus barefoot in quadriplegia
allocation of
participants

This criterion is cited but not used to compute the total PEDro score.

( 8%) but unchanged in hemiplegia and diplegia [7].

Random

Just one study assessed the effect of FRO on energy expenditure

in children with CP [5]. Diplegic children showed decreased EEI
Yes
Yes

Yes

Yes
Yes
No

No

No

No
No
No
No
No
No
No
No
No

with FRO versus barefoot (0.40 vs 0.52 beats/m) (P = 0.035) [5].

Eligibility
criteriona

3.4.2. Walking speed

The effect of AFOs on walking speed was analyzed in 10 studies
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

(a healthy childs walking speed is 1.4 m/s) [4]. Speed of walking

improved signicantly by about 34% with SAFO versus barefoot
evidence

walking [7], with the greatest improvements in diplegic CP

Level of

(P > 0.01) [10]. However, Vanwala et al. evaluated the effect of a

III

III
III
III

III
III
III
III
III
III
III
III
III

DAFO on walking speed in diplegic CP, reporting decreased speed

II
II

II
II

with SAFO versus barefoot (0.148  0.18 vs 0.22  0.16 m/s)

(P < 0.5) [6].
Rogozinski et al., 2009 [27]
Jagadamma et al., 2014 [4]

Schweizer et al., 2014 [26]

Van Gestel et al., 2008 [9]

Dalvand et al., 2013 [19]

Lucareli et al., 2007 [11]

Bennett et al., 2012 [12]

In hemiplegic CP, gait velocity increased signicantly with

Vanwala et al., 2014 [6]
El-Kafy et al., 2014 [18]

Caliskan et al., 2013 [5]

Balaban et al., 2007 [8]

Hayek et al., 2007 [10]

Butler et al., 2007 [23]
Wren et al., 2015 [21]

Brehm et al., 2008 [7]

Zhao et al., 2013 [20]
Ries et al., 2015 [28]

HAFO [8,26], but Bennet et al. showed walking speed not affected
by AFO [12]. In diplegic CP, gait velocity was meaningfully
improved, from 0.631.06 m/s with barefoot walking to 0.74
Author, year

1.03 m/s with HAFO [8,10,12].

Walking speed improved signicantly by 9% with PLS in
Table 1

hemiplegic CP [7,9]. Two studies showed increased walking speed

a

with FRO in diplegic CP (from 0.44.5  3.23 to 0.83  0.19 m/s,

Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004

Table 2
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004
Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
Participants, methods, outcomes, results and conclusions.
Author Study design Sample Participant
size characteristics
Ries, et al., 2015 [28] Cross-sectional 378 Children with diplegic CP, Barefoot
mean age 9.8  3.8 years
Wren et al., 2015 [21] Cross-over RCT 10 6 girls and 4 boys with
cerebral palsy (412
years)
5 diplegic
5 hemiplegic
El-Kafy et al., 2014 [18] RCT 57 31 boys and 26 girls with
spastic diplegic CP
Mean age 68 years
Jagadamma et al., 2014 [4] Cross-sectional within 19 5 girls and 3 boys mean
and between group age 515 years
Hemiplegia (n = 4)
Diplegia (n = 4)
11 healthy children 5 and
15 years old
Vanwala et al., 2014 [6] Cross-sectional study 21 5 girls and 16 boys with Solid AFO vs barefoot
within group mean age 6.85 years
Diplegic (n = 13)
Hemiplegic (n = 1)
Triplegia (n = 6)
Quadri (n = 1)
MAS < 3 with GMFCS level
1, 2, 3
Intervention(s) vs Procedure
control condition
Differences between
Solid AFO walking with AFOs and
Hinged AFO walking barefoot were
PLS recorded
Data were collected using
a Vicon 3-D motion
capture system
Dynamic AFO (DAFO) Children wore DAFO and
Adjustable dynamic- ADR-AFO, each for
response AFO (ADR-AFO) 4 weeks, in randomized
order. Gait analysis using a
Vicon 612 motion capture
system with 4 in-oor
triaxial force plates
Group A without orthoses Children underwent
just traditional neuro- treatment for 2 hr daily,
developmental physical for 12 weeks
therapy Gait parameters were
Group B with the evaluated pre- and post-
TheraTogs treatment by using a 3-D
Group C with the motion analysis system
TheraTogs and solid
ground reaction AFO
Barefoot Children underwent gait
Non-tuned rigid AFO- analysis at a self-
footwear combination determined speed with
(AFO-FC) 3 conditions
Tuned rigid AFO-FC Vicon 3-D motion analysis
system
Participant walked for
10 m with AFO rst and
then barefooted and vice
versa. 10-min rest was
given between 2 10-m
walk tests (i.e., with and
without AFO)
REHAB-1091; No. of Pages 10
G Model
Outcome measures (ICF) Results and conclusions
GDI Only step length exhibited clinically
Step length (body function meaningful improvements for the average
and structure) AFO users. Changes in step length and speed
Gait speed (activity) (with an average speed increase of 34% and
step length increased by 18%) and GDI were all
statistically signicant (P < 0.001)
Conclusion: AFO for children with CP results in
consistent gait improvements in step length
Kinetics kinematics Children demonstrated better stride length
Temporal-spatial analysis (1112 cm), hip extension (2848), and swing
A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx
(body function and phase dorsiexion (98178) in both AFOs vs
structure) barefoot condition. Push-off power (0.3 W/kg)
Gait speed (activity) and knee extension (58) were better with ADR-
AFO than DAFO
Conclusion: ADR-AFOs produce better knee
extension and push-off power; DAFOs
produce more normal ankle motion. Both
DAFOs provide improvements over barefoot
Kinematics Statistically signicant differences among the
Temporal-spatial analysis 3 groups post-treatment in gait speed,
(body function and cadences, and stride length (P-values 0.03,
structure) 0.011, and 0.001 respectively). Signicant
Gait speed (activity) post-treatment differences for bilateral hip
and knee exion angles
Conclusion: solid ground reaction AFO
combined with the TheraTogs strapping
system improved gait more than conventional
treatment
Kinetics Stride length (P = 0.01) and walking speed
Kinematics (P = 0.04) were signicantly greater with non-
Temporal-spatial (body tuned AFO-FC vs barefoot, lower peak knee
function and structure) extension with tuned AFO-FC vs non-tuned
Walking speed (activity) AFO-FC (P = 0.04). No differences in hip and
pelvis kinematics in any of the comparisons.
Peak knee extension moments were
signicantly lower (P = 0.001) and peak ankle
plantar exion moments were signicantly
higher (P = 0.01) vs non-tuned AFO-FC
Conclusions: potential benets of using rigid
AFO-FC
EEI Mean EEI with barefoot was 158.8  2.37 and
Walking speed (activity) with AFO was 370.4  3.93. Speed with barefoot
was 0.22  0.16 m/s and with AFO was
0.148  0.18 m/s. Signicant difference in gait
speed and EEI between the groups. P < 0.05
Conclusion: increase in EEI and decrease in gait
speed in children with spastic CP with dynamic
AFO
5

Table 2 (Continued )
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004
Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
Author
Schweizer et al., 2014 [26]
Dalvand et al., 2013 [19]
Zhao et al., 2013 [20]
Caliskan et al., 2013 [5]
Bennett et al., 2012 [12]
6
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Study design Sample Participant Intervention(s) vs Procedure Outcome measures (ICF) Results and conclusions
size characteristics control condition
Cross-sectional within 40 23 hemiplegic CP (9 girls Hinged AFO vs barefoot Patients walked barefoot Gait speed (activity) Walking speed, step length, and time to foot
and between group and 14 boys) with mean and hinged AFO at a self- Kinematics off were signicantly increased in the hinged
age 12.4 years (range 8 selected speed on a 10-m Temporal-spatial (body AFO condition on the hemiplegic side vs the
18) level ground walkway in function and structure) same side in the barefoot condition. The
17 healthy control group same day cadence was signicantly decreased.
(8 girl/9 boy). Mean age Gait analyzed by a VICON Statistically signicant differences pelvic tilt
12.8 years (range 818) motion analysis system range of motion (barefoot: 7.58 (6.19.08),
orthosis: 6.68 (5.18.1) P = 0.040)
Conclusion: hinged AFO, restoring the rst
ankle rocker, had no clinically relevant effects
on trunk kinematics
Clinical trial pre-/post- 30 30 children with spastic Hinged AFO Each group was randomly GMFM (activity) Signicant difference when comparing hinged
A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx
design diplegia, aged 48 years Solid AFO assigned to one of the AFO with solid AFO (P < 0.05) and controls
Severity of CP was based Barefoot therapy methods. (P < 0.01) in improved gross motor function,
on GMFCS Control group just Participants were but no signicant difference between solid
occupational therapy instructed to wear AFOs AFO and controls (P = 0.631)
regularly for 3 months, Conclusion: gross motor function was
6 hr daily. Abilities of gross improved in all groups; however, hinged AFO
motor function were appears to improve the gross motor function
assessed using GMFM-88 better than solid AFO and than control groups
RCT 112 Children with spastic Hinged AFO Passive ankle dorsiexion Passive ankle range of Signicant baseline post intervention
diplegia level I and II of the During day vs night angle and 66-item GMFM motion (body function and improvements in passive ankle dorsiexion
GMFCS (70 boys and were recorded by hinged structure) angle and the 66-item GMFM in both groups
42 girls); mean age AFO during the day and GMFM (activity) (P < 0.05). On the basis of the score changes,
2  6.93 years (range 14) the night. Assessments no signicant difference between the 2 groups
were performed at with respect to passive ankle dorsiexion
baseline and at the end of angle. However, the improvements in the 66-
the 8 weeks training item GMFM were signicantly better in the
day AFO-wearing group (P < 0.01)
Conclusion: daytime use of AFOs was more
effective in improving GMFM scores than day-
night use
Cross-sectional within 48 Mean age was 7.4 years Solid AFO (polyethylene Energy expenditures EEI, MAS index, SMC and Walking efciency was more signicant in
and between group (range 413) AFO; PAFO) determined based on heart GMFCS (activity) patients with solid PAFO (P < 0.05). In children
35 bilateral spastic type, Articulated PAFO rate, yielded an EEI with with solid PAFO, EEI values were lower
9 with mixed type and Ground and without AFO during (0.25 beat/m) than value without AFO
4 dyskinesia type Reaction AFO walking (0.38 beat/m). Use of metallic AFO increased
Spasticity and severity Metallic AFO vs barefoot EEI vs the non-orthosis group. No signicant
evaluated by MAS and difference between groups in GMFCS and MAS
(GMFCS) (P < 0.05).
Voluntary motor control Conclusion: especially solid PAFO can be more
evaluated with selective benecial in terms of energy consumption in
motor control (SMC) CP
Cross-sectional study 21 5 girls and 16 boys with Hinged AFO Participants walked at Kinematics kinetics (body AFOs increased stride length by 13%
between groups spastic diplegia (mean age Solid AFO their self-selected speed function and structure) (P < 0.005) and tended to increase preferred
9.6  4.12 years) Barefoot and 3-D kinematic data Gait speed (activity) walking velocity. No change in the mechanical
10 children wore hinged were collected by work performed to walk or the normalized
AFO 8 camera Vicon motion center of mass vertical excursion
11 children wore solid AFO analysis system Conclusion: current AFOs can reduce the work
Mean GMFM was 93  7 to walk, but not for many children with CP

Table 2 (Continued )
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004
Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
Author
Rogozinski et al., 2009 [27] Case series
Brehm et al., 2008 [7]
Van Gestel et al., 2008 [9]
Study design Sample Participant
size characteristics
27 19 boys and 8 girls with a FRO vs barefoot
mean age 12.4  2.4 years
24 diplegic, 1 triplegic;
2 quadriplegic
Functional level
determined by the GMFCS
II, III
Cross-sectional within 181 110 boys and 71 girls with Solid AFO + shoe
group spastic cerebral palsy with PLS + shoe
mean age 9 years (range Barefoot
4.618.4)
23 hemiplegia
103 diplegia
55 quadriplegia
Cross-sectional study 36 Children (22 girls, 15 boys)
within and between with hemiplegia, mean
groups age 8.5  2.8 years (range
410)
GMFCS Level I and II
Intervention(s) vs Procedure
control condition
Bilateral 3-D kinematic
and kinetic data collected
by using a 12-camera
motion measurement
during walking both
barefoot and with FRO
A breath-by-breath gas- Oxygen consumption
analysis system was used Speed and GGI (activity)
for assessment of oxygen
consumption
For the biomechanical
analysis of gait, children
walked at a self-preferred
pace along a 10-m
walkway. Data were
captured by using a VICON
PLS Children walked barefoot
CFO (Dual Carbon Fibre and with 3 types of AFOs
Spring AFO) compared by objective
Orteams (orthoses with gait analysis, including 3- and structure)
the dorsal part containing D kinematics and kinetics
11 sleeves)
Barefoot
REHAB-1091; No. of Pages 10
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Outcome measures (ICF) Results and conclusions
Kinematics and kinetics The mean sagittal plane dynamic range of
(body function and motion of the ankle in stance was reduced
structure) from 23  9 when walking barefoot to
10  3 with the orthosis (P < 0.001), and the
mean peak knee extension in midstance
improved from 29  14 of exion to 18  14 of
exion (P = 0.013). The mean minimum sagittal
knee moment in midstance improved from an
internal knee extensor moment of 0.2  0.3 Nm/
kg to an internal knee exor moment of
20.1  0.3 Nm/kg (P = 0.072).
Conclusions: the best outcomes with FRO, as
A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx
determined by peak knee extension in
midstance, were with knee and hip exion
contracture of 10 degrees
Speed improved signicantly by 8.2% with
solid AFO (P < 0.001) and 9.0% with PLS
(P < 0.001). Cost of walking was 6% lower with
AFO (P = 0.007) (a signicant decrease in cost
of walking for PLS walking (8%), whereas for
solid AFO, walking remained unchanged). The
GGI remained unchanged (P = 0.607). Changes
in minimum knee exion angle in stance
phase and in terminal swing (P = 0.013 and
P = 0.022, respectively)
Conclusion: AFO signicantly decreased the
energy cost of walking of quadriplegic
children with CP, compared with barefoot
walking, but remained unchanged with
hemiplegic and diplegic CP
Kinematics and stride- Cadence signicantly decreased and step
temporal, lower limb length and walking velocity signicantly
moment (body function increased with orthoses (all P = 0.001). Knee
range of motion during shock absorption,
Gait speed swing kinematics, and most knee kinetics also
GMFCS (activity) signicantly changed (P = 0.0010.004). About
half of the hip kinematics showed a signicant
effect of orthoses and all hip moment and
power were signicantly increased (P = 0.001
0.006). Only the CFO could signicantly
improve ankle dorsiexion at loading
response vs the barefoot condition (P = 0.007)
Conclusion: although the PLS ensured the
highest correction at the ankle around initial
contact, the CFO created a signicantly higher
maximal hip exion moment in stance
7

Table 2 (Continued )
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004
Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
Author
Balaban et al., 2007 [8]
Butler et al., 2007 [23]
Hayek et al., 2007 [10]
Lucareli et al., 2007 [11]
AFO: ankle foot orthosis; EEI: Energy Expenditure Index; FRO: oor reaction AFO; GDI: Gait Deviation Index; GGI: Gillette Gait Index; GMFCS: Gross Motor Function Classication System; GMFM: Gross Motor Function Measure; ICF:
International Classication of Functioning; MAS: Modied Ashworth Scale; PLS: posterior leaf spring AFO; RCT: randomized controlled trial.
8
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Study design Sample Participant Intervention(s) vs Procedure Outcome measures (ICF) Results and conclusions
size characteristics control condition
Cross-sectional study 11 Children with hemiplegic Hinged AFO vs barefoot Children walked at a self- Kinetics Oxygen consumption was signicantly
within groups CP (7 boys, 4 girls) with selected speed along a 10- reduced during AFO walking (P < 0.05)
Kinematics (body function
the mean age m walkway with and and structure) energy(walking was 8.81 + 1.68 mL/kg/min with AFO
7.18 + 1.16 years without AFO. Walking and was 9.50 + 1.83 mL/kg/min without).
consumption (activity)
energy expenditure Walking speed was increased (P < 0.01) with
measurements involved a AFO. Knee exion at initial contact was
breath method with an decreased (P = 0.02). Ankle dorsiexion during
open-circuit indirect midstance also increased signicantly vs the
calorimeter barefoot condition. The angle position at
Vicon motion analysis midswing changed from
system was used for gait 73.61 + 6.23 plantarexion to
analysis 8.27 + 4.96 dorsiexion with AFO (P < 0.01).
A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx
Peak ankle power generation in stance phase
was signicantly decreased with hinged AFO
walking (1.61 + 1.17 W/kg) compared to
barefoot (1.96 + m1.25 W/kg)
Conclusion: the hinged AFO is useful in
reducing the energy expenditure of gait in
children with hemiplegic spastic CP
Cross-sectional study 21 Children aged 412 years Fixed AFO vs barefoot The children walked at Kinematics Children who tuned showed exion of no
within groups 12 diplegia their self-selected speed Kinetics (body function more than 20-degree in the rst third of stance
7 hemiplegia on ORLAU gait Laboratory and structure) combined with movement toward extension
1 quadriplegia system in the second third of stance to a minimum of
1 athetoid 10-degree exion or less (P = 0.0143)
Conclusion: children likely to benet from
AFO tuning
Cross-sectional 56 Children (32 boys and Rigid AFO Children walked along a Kinetics kinematics In the hemiplegic group, stride length was
24 girls), mean age Articulated AFO 12-m walkway at self- temporal-spatial (body 11.7% (P = 0.001) longer and cadence was
8.9 years (range 417) Barefoot selected velocity, rst function and structure) reduced by 9.7% with AFO. Walking speed was
38 diplegic barefoot and then with not affected. In the diplegic group, stride
18 hemiplegic AFO length with AFOs was 17.4% longer compared
GMFCS analysis 3-D gait analyses by a to barefoot (P = 0.001) and walking velocity
VICON motion analysis improved by 17.8% (P = 0.001); cadence was
system unchanged. AFOs increased ankle dorsiexion
Kinetic data were at initial contact in both groups. In the
collected by using 4 AMTI hemiplegic group, knee exion at initial
force plates contact was reduced by 8.5 degree (P = 0.032),
with no effect in the diplegic group. The
proportion of patients that reached symmetry
at initial double support increased from 5.6%
to 16.7% with AFO
Conclusions: AFO improved spatio-temporal
gait parameters in children with spastic CP
Cross-sectional 71 Diplegia children, mean Floor reaction AFO vs Children walked with and Ankle and knee and hip Maximum knee extension and ankle
age 12.2  3.9 years barefoot without AFO and motion kinematics (body function dorsiexion were signicantly improved in
Group I with limited analysis laboratory and structure) groups II and III with vs without a brace, with
extension recorded gait kinematics no change in group I (ankle kinematics:
Group II with moderate 9.5  6.5 [P > 0.05], knee kinematics
limited extension 6.1  9.4 [P > 0.05]) The maximum hip
Group III, crouch extension was not signicant in all 3 groups
(P > 0.05)
Conclusion: when indicated to improve the
extension of the knees and ankle in the stance of
children with CP, FRO was effective
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A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx
P < 0.001) [18,27]. However, Wren et al. showed increased walking
speed with DAFO (from 0.72  0.34 to 0.780.84 m/s) [21].
3.4.3. Functional skills
Total gross motor function scores differed before and after SAFO
in diplegic CP [19]. Changes in the Gillette Gait Index (GGI) were
not statistically signicant, with a decit of 10% shown by use of
SAFO [7]. HAFO in diplegic CP improved the 66-item Gross Motor
Function Measure (P < 0.05) [20]. Both HAFO and SAFO signi-
cantly improved gross motor function versus barefoot walking in
diplegic CP [19], with a meaningful difference between S/HAFO and
barefoot walking in the Gait Deviation Index in diplegic CP
[24]. Changes in GGI were not statistically signicant, with an
improvement of 5% with PLS versus barefoot [7].
4. Discussion
Our review suggests some positive effects of AFOs on spatial-
temporal and kinematic parameters (such as improvement in gait
speed, stride length, single support time and symmetry), gait
kinetics, energy expenditure and functional skills in children with
spastic CP.
4.1. Effect of SAFO on walking variables
SAFO increased stride length in CP, although we found
inconsistent results for the effect of SAFO on cadence. It also
improved walking speed the most as compared with PLS and HAFO
in children with diplegic CP. SAFO reduced peak ankle power
during terminal stance, which implies improved gait pattern at the
expense of a reduced power generation at push-off. In diplegic CP,
solid PAFO can be more benecial in energy consumption as
compared with metallic AFO. SAFO can normalize ankle function
the most by simply restricting the ankle to a single neutral angle in
diplegic CP. Findings show an improvement in knee exion angles,
reecting a reduction in the required muscle force during stance
phase [7]. Energy cost reduction was related to both a faster and
more efcient walking pattern with AFO. The improvements in
efciency were reected by changes of stance and swing phase
knee motion (i.e., children with improved knee exion angle
toward the typical normal range demonstrated a decreased energy
cost of walking and vice versa [7]).
4.2. Effect of HAFO on walking parameters
Stride length, walking speed, single limb support and gait
symmetry were improved with HAFO. HAFO had positive effects on
ankle and knee ROM and ankle power in hemiplegic CP. It was also
effective in decreasing energy expenditure in hemiplegic CP. HAFO
allows for free ankle dorsiexion with blocked plantarexion
preventing dynamic equine deformity of the ankle joint at initial
foot contact, thus producing physiological heel contact, and was
effective in restoring the rst ankle rocker of gait [8]. Improve-
ments in gross motor function were also evident [19]. HAFO may
provide free dorsiexion in the stance phase and limited
plantarexion (usually 908) that normalizes ankle motion during
the stance phase of gait and facilities the performance of
developing motor skills [29].
4.3. Effect of FRO on walking parameters
FRO increased stride length, cadence and speed of walking in
diplegic CP. FRO was effective in improving knee extension. The
ground reaction vector is directed anterior to the knee joint,
providing an extensor moment at the knee and reducing demands
on the quadriceps [30]. Sagittal plane knee moments in midstance
Please cite this article in press as: Aboutorabi A, et al. Efcacy of ankle foot orthoses types on walking in children with cerebral palsy: A
systematic review. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.05.004
9
were changed internally from extension to exion moments by
FRO, which also was the most effective in providing integrity to the
ankle plantarexionknee extension couple [31]. This is a critical
biomechanical concept in understanding the inter-relations
among the foot, ankle and knee levels. A stable foot in the line
of progression, when acted on by a competent calf muscle (gastro
soleus), controls the progression of the tibia over the plantargrade
foot during the stance phase of gait [30]. However, knee exion
contractures of > 15 deg should be considered a contraindication
to prescription of FRO or should be addressed (surgically) before
the use of FRO [27].
4.4. Effect of PLS on walking parameters
PLS was effective in improving knee exor moments and
walking speed in hemiplegic CP. A spring-like AFO can enhance
push-off and may potentially reduce energy cost. The orthotic
improved knee and ankle ROM in hemiplegic CP and signicantly
decreased the energy cost of walking in quadriplegia, but only in
single studies.
4.5. Effect of DAFO on walking parameters
DAFO and a spring-like AFO produced more normal ankle
kinematics and kinetics through late stance and also allowed for
more normal push-off power at pre-swing, which may improve the
energy efciency of gait [21]. DAFO can promote a more exed
posture (more dorsiexion and knee exion during stance), so with
an equinus pattern or dropped foot, DAFO is efcient for children
with a crouched gait pattern.
4.6. Clinical implications
The goal from any intervention must be determined by
considering the requirements of the child and the parents, in
conjunction with the input of a multi-professional team. Individual
factors (e.g., age, type of CP and level of Gross Motor Function
Classication Scale) should be considered when selecting an AFO
for children with CP. This study showed that stride length, walking
speed, single limb support and gait symmetry were improved with
HAFO in children with hemiplegic CP. HAFO can be effective in
spastic hemiplegic CP by naturalizing the gait pattern. HAFO,
specically with a conguration that enabled ankle dorsiexion,
enhanced coordination, facilitated a more normal weight shift in
all planes, and improved gait symmetry in hemiplegic CP [10]. In
older children with spastic CP, the gait pattern shifted from a true
equinus and jump gait to an apparent equinus and crouch gait.
Therefore, because of the ankle normal position in apparent
equinus and ankle dorsiexion in crouch gait, HAFO does not
prevent knee exion, so it cannot improve the standing and
walking functions in children with diplegic CP [19]. Some children
with severe spasticity and diplegic CP are also likely to experience
clinical benet due to the decrease in energy expenditure
associated with SAFO and FRO. FRO proved to be the most
effective in providing the integrity of the ankle plantarexion
knee extension couple in children with a crouched gait pattern
[31].
4.7. Limitations
From 17 studies in this review, just 4 had a pre-test/post-test
with control group design and a randomization procedure
with adequate internal validity conrmed by an adequate or
above PEDro score (5,7,9/10) and level II evidence [18
21]. Additionally, the accepted signicance values varied
among the studies (i.e., P < 0.05 or P < 0.01), which limited
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10 A. Aboutorabi et al. / Annals of Physical and Rehabilitation Medicine xxx (2017) xxxxxx
the statistical comparison of heterogeneous results between
different studies.
In addition to potential performance and measurement bias
(lack of blinded assessment) in some studies, signicant sources of
selection bias were often present, including heterogeneity in
patient populations, AFO ttings, and outcome measures, which
prevented a direct quantitative analysis. Further studies are
needed, including a high-quality RCT, which provides the best
design to control for potential bias [32]. Cross-over and single-
subject designs are also powerful alternative designs to RCTs for
children with CP. Furthermore, this design allows for detailed
investigation of individual characteristics that are important in a
population with widely varied structural and functional characte-
ristics [33].
The lack of consistency in the terms used for AFOs was another
source of selection bias. Fourteen different terms were used to
describe different types of AFOs, which indicates a lack of standard
terminology. According to the Alexander and Xing terminology
[22] we grouped 14 terms into 5 main AFO types, for a clearer
description of AFOs and easier comparison between studies. The use
of a standard terminology should be considered in future studies.
Outcomes were restricted to the body structure and function
and activity domains of the ICF-CY. We found no study that
included outcomes such as level of participation and environmen-
tal factors. The use of the ICF-CY in future studies would provide an
outline for the investigation of all the functional components.
Because most of the studies compared walking with an AFO to
barefoot walking, more studies are needed with different AFOs used
in the same group of children to help in clinical decision-making
about which AFO type should be used. In addition, few studies
examined PLS and DAFO (3 of PLS, 1 of DAFO) for gait parameters in
children with CP, so further studies in this eld are required.
5. Conclusions
Evidence showed improvement in gross motor function with
HAFO and SAFO in children with diplegic CP. AFOs could also
improve ankle and knee ROM, walking speed and stride length.
HAFO, CFO and DAFO were effective in restoring ankle rockers
during gait and producing a more normal physiological gait
pattern. HAFO can decrease energy expenditure and improve gait
parameters in hemiplegic CP. SAFO and FRO were effective in
improving gait parameters and reducing energy expenditure in
diplegic CP. Because most studies examining the efcacy of HAFO,
SAFO, and PLS had weak level of evidence and a poor-quality Pedro
score, further studies providing valid and high-quality evidence are
needed to support better-informed clinical practice in the use of
AFOs in children with CP.
Funding
We thank the University of Social Welfare and Rehabilitation
Sciences for nancial support for this research.
Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgements
None declared.
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