Effect of ankle-foot orthoses on gait, balance and gross motor function in children with cerebral palsy: a systematic review and meta-analysis.

OBJECTIVE: To determine the effects of ankle-foot orthoses (AFOs) on gait, balance, gross motor function and activities of daily living in children with cerebral palsy. DATA SOURCES: Five databases were searched (Pubmed, Psycinfo, Web of Science, Academic Search Premier and Cochrane Library) before January 2018. REVIEW METHODS: Studies of the effect of AFOs on gait, balance, gross motor function and activities of daily living in children with cerebral palsy were included. Articles with a modified PEDRO score ≥ 5/9 were selected. Data regarding population, AFO, interventions and outcomes were extracted. When possible, standardized mean differences (SMDs) were calculated from the outcomes. RESULTS: Thirty-two articles, corresponding to 56 studies (884 children) were included. Fifty-one studies included children with spastic cerebral palsy. AFOs increased stride length (SMD = 0.88, P < 0.001) and gait speed (SMD = 0.28, P < 0.001), and decreased cadence (SMD = -0.72, P < 0.001). Gross motor function scores improved (Gross Motor Function Measure (GMFM) D (SMD = 0.30, P = 0.004), E (SMD = 0.28, P = 0.02), Pediatric Evaluation of Disability Inventory (PEDI) (SMD = 0.57, P < 0.001)). Data relating to balance and activities of daily living were insufficient to conclude. Posterior AFOs (solid, hinged, supra-malleolar, dynamic) increased ankle dorsiflexion at initial contact (SMD = 1.65, P < 0.001) and during swing (SMD = 1.34, P < 0.001), and decreased ankle power generation in stance (SMD = -0.72, P < 0.001) in children with equinus gait. CONCLUSION: In children with spastic cerebral palsy, there is strong evidence that AFOs induce small improvements in gait speed and moderate evidence that AFOs have a small to moderate effect on gross motor function. In children with equinus gait, there is strong evidence that posterior AFOs induce large changes in distal kinematics.

Early Botulinum Toxin Injections in Infants With Musculoskeletal Disorders: A Systematic Review of Safety and Effectiveness.

OBJECTIVE: To report current evidence regarding the safety of intramuscular botulinum toxin injection (BTI) in children with orthopedic- and neurologic-related musculoskeletal disorders >2 years of age. DATA SOURCES: PubMed, Cochrane Library, and ScienceDirect, Google Scholar, and Web of Science. STUDY SELECTION: Two reviewers independently selected studies based on predetermined inclusion criteria. DATA EXTRACTION: Data relating to the aim were extracted. Methodologic quality was graded independently by 2 reviewers using the Physiotherapy Evidence Database scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs. Level of evidence was determined using the modified Sackett scale. DATA SYNTHESIS: Data of 473 infants were analyzed. Fifty-five infants had cerebral palsy, 112 had obstetric brachial plexus palsy, 257 had clubfoot, and 44 had congenital torticollis. No studies reported any severe adverse event that could be attributed to the BTI. The rate of mild to moderate adverse events reported varied from 5% to 25%. Results regarding efficacy were preliminary, dependent on the pathology, and limited by the small number of studies and their low levels of evidence. CONCLUSIONS: BTI is already widely used as an early treatment for this age group. The safety profile of BTI in infants appears similar to that of older children and risks appear more related to the severity of the pathology and the location of the injections than to the toxin itself. Regarding effectiveness, other studies with higher levels of evidence should be carried out for each specific pathology.

Care-related pain and discomfort in children with motor disabilities in rehabilitation centres.

BACKGROUND: Pain is one of the symptoms reported most by children with motor disabilities particularly during daily living activities in institutions and during rehabilitation. Despite the care and consideration of professionals, a wide range of motor and cognitive disabilities, limited communication skills, the presence of chronic pain and frequent care interventions place such children at high risk of experiencing induced pain. OBJECTIVES: We aimed to identify care-related pain and discomfort in children with motor disabilities in rehabilitation centres and the characteristics of children at risk of induced pain. A further aim was to evaluate the validity of a method for the continuous assessment of care-related pain. METHODS: Patients were recruited from 2 paediatric rehabilitation centres. The level of pain or discomfort experienced during each daily care activity was evaluated for 5 days and 1 night by using the FLACC-r scale and a visual analog scale (VAS) rated by the caregiver (VAS caregiver) and the patient (VAS patient). RESULTS: We included 32 children (mean age: 8.5±5 years, range: 1-15 years) with 1302 care activities evaluated. Overall, 3.6% of the activities were rated as painful and 11% uncomfortable. The most frequent painful activities were mouth care, transfers standing and dressing. The most frequent uncomfortable activities were passive limb mobilisation, dressing and transfers. Children with neurological disorders were at increased risk of induced pain. CONCLUSIONS: Children with motor disabilities experienced pain during daily care activities. The methodology we propose is valid and can be used in any type of institution for children with motor disability to evaluate and reduce the frequency of care-related pain.