Optimal alignment of ankle foot orthoses in cerebral palsy

脑瘫（CP）是儿童时期最常见的严重身体残疾。它是由发育中的大脑受到神经损伤引起的，每1000个活产婴儿中有2-3人受到影响，其发病率是儿童关节炎的20倍，是儿童白血病的500倍。根据卫生部国家长期疾病服务框架（2005年），CP的患病率为每10万例人口中186例，高于多发性硬化症（120/10万）和脊髓损伤（50/10万）的患病率，也高于帕金森病（200/10万）。在西方世界，CP的发病率几十年来一直保持稳定。虽然最初的脑损伤是永久性的和不变的，但在生长过程中会出现进行性肌肉骨骼畸形。这种畸形导致进行性严重残疾，在社会层面产生深远影响，并造成沉重的经济负担。在美国，2003年每个孩子每年的直接生命周期成本为92.1万美元，而在欧洲，间接成本高出2-5倍，2009年直接成本超过80万欧元。患有CP的儿童经常接受矫形外科手术，目的是改善功能预后并尽量减少功能衰退。双瘫是CP的一种形式，主要涉及腿部并限制行走能力。在最严重的情况下，孩子将无法行走，在不太严重的情况下，他们的能力将受到严重限制，通常需要使用矫形器和助行器来实现任何合理的功能。踝足矫形器（AFO's）是各种神经系统疾病（如脑瘫、中风和多发性硬化症）中常见的矫形治疗方法，通常用于限制或允许关节处发生特定运动。这些矫形器处方的通常护理途径是由矫形师（大多数没有技术投入）评估，为个体开出最相关的角度（90度，跖屈，背屈）。以前，文献表明踝关节足矫形器在几个方面对儿童有有益的影响（临床、生物力学、生理学）。然而，有一种观点认为，儿童应该有他们的AFO的最佳对齐，以鼓励典型的步行和挑战肌肉骨骼系统。这可能会使肌肉得到拉伸，这将有助于特定关节的活动范围，并减少挛缩的风险，而挛缩是脑瘫的一个主要问题。灰色文献中有一些轶事信息提供了一些证据，但需要严格的同行评审证据。这项研究将直接与对齐诊所联系起来，该诊所与伦敦矫形咨询公司（London Orthotic Consultancy）一起，特别是伊莱恩·欧文（Elaine Owen）。作为该诊所的一部分，拟议的KTP正在开发中，旨在改变公司内部的临床实践和审计跟踪，该博士学位将进一步使整个项目向前发展。

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.