Page 19 - Maximizing the efficacy of ankle foot orthoses in children with cerebral palsy

The absence of such information hampers to unravel the nature of the optimal match between the patient and the AFO, and to define the causes of the AFO’s (in)efficacy. Moreover, a variety of AFOs in relation to the underlying impairments and gait deviations of participants is introduced by differences in the prescription process, which is currently largely dependent on clinical experience[48,49] as clear prescription guidelines are scarce[36,51]. The insufficient information and variety between studies prevents a fair comparison of results, and reduces the potential to perform meta-analyses to provide more substantial evidence to improve prescription guidelines[50]. Evidence for AFO efficacy in CP could be improved by good quality research using strong designs that can control for confounding factors[48,50], providing unambiguous characteristics of the participants’ walking biomechanics and the mechanical properties of the applied AFOs.
Another problem within AFO research concerns the lack of consistency in outcomes to report AFO efficacy. To evaluate of the effects AFOs on gait, Brehm et al.[52] suggested a core set of outcomes, covering measures on all domains of the International Classification of Functioning, Disability and Health (IFC) framework[53]. This is the common framework for the assessment of functioning and treatment planning of patients in rehabilitation medicine[53]. The ICF framework uses the domains of ‘body functions and structures’ ‘activities’ and ‘participation’ to describe the impact of a disease or disability on human functioning, which can also be affected by ‘personal factors’, and ‘environmental factors’. The domain ‘body functions and structures’ describes a person’s functioning on the level of the physiological functions of body systems and the body’s anatomical structures. The ‘activity’ domain describes human functioning in terms of daily-life activities, and can be sub-divided into the capacity and performance qualifiers. The first refers to what a person can do in, for example, a laboratory setting, while the latter describes what a person actually does in day-t0-day life. The ‘participation’ domain refers to a person’s participation in daily life situations, such as sports, and social events.
From the patient’s perspective, it is most relevant to assess the effect of an AFO on outcome measures that express the gain for the patient; for example, a measure that quantifies walking capacity such as walking speed or walking energy cost. Additionally, an assessment of daily walking activity (i.e. walking performance) may give insight in the patient’s functioning in daily life. The effects of an AFO on gait biomechanics, assessed with a 3D gait analysis, can also be evaluated, representing the biomechanical functioning of an AFO (i.e. at level of body functions and structures)[37]. It has been suggested that outcome measures in studies on AFO efficacy should cover both the activity level and the level of body functions and structures[37]. This could reveal mutual relations between
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