Optimal alignment of ankle foot orthoses in cerebral palsy

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Cerebral Palsy (CP) is the most common serious physical disability in childhood. It is caused by neurological insult to a developing brain, affecting 2-3 per 1000 live births, making it 20 times more common than childhood arthritis, and 500 times more common than childhood leukaemia. According to the Department of Health National Service Framework for Long Term Conditions (2005) the prevalence of CP is 186 per 100,000 cases of population, higher than the prevalence of multiple sclerosis (120/100,000) and spinal cord injury (50/100,000), and like that of Parkinson's (200/100,000). Incidence rates of CP have remained stable over several decades in the western world. Although the initial brain lesion is permanent and unchanging, progressive musculoskeletal deformity develops during growth. This deformity causes progressive severe disability, with a profound impact at a societal level and high economic burden. In the US the direct annual lifetime cost per child in 2003 was $921,000 and the indirect costs 2-5 times higher in Europe with a direct cost exceeding 800,00 euros in 2009. Children affected with CP frequently receive orthopaedic surgery with the intent to improve functional outcomes and minimise functional decline. Diplegia is the form of CP that involves predominantly the legs and restricts the ability to walk. In the most severe cases a child would be unable to walk, and in less severe cases their ability would be significantly restricted and often require the use of orthotics and walking aids to achieve any reasonable function. Ankle Foot Orthoses (AFO's) are common orthotic treatments in a variety of neurological disorders (e.g., cerebral palsy, stroke and multiple sclerosis) and are generally fitted to restrict or allow specific motion to occur at joints. The usual care pathways for the prescription of these orthoses would be an evaluation by an orthotist (majority with no technological input) to prescribe the most relevant angle (90 degrees, plantarflexed, dorsiflexed) for the individual. Previously, literature has shown that ankle foot orthoses have beneficial effects on the child in several ways (clinically, biomechanically, physiologically). However, there is an opinion that children should have optimal alignment of their AFO's to encourage typical walking and to challenge the musculoskeletal system. This may allow a stretch of a muscle to occur which would aid the range of motion at a particular joint and reduce the risk of contractures which are a major issue in cerebral palsy. There are anecdotal information in the grey literature which give some evidence but rigorous peer-reviewed evidence is needed. This piece of research would link directly with the Alignment clinic that is running out of the University alongside London Orthotic Consultancy and with Elaine Owen in particular. As part of this clinic, a proposed KTP is being developed which would aim to alter the clinical practices and audit trail within the company and this PhD would further benefit the whole project going forward.