Rehabilitation After Surgical Reconstruction to Restore Function to the Upper Limb in Tetraplegia: A Changing Landscape.

Upper limb reconstructive surgical procedures for individuals with tetraplegia are performed in many centers internationally. Most recipients of surgery return to local communities and nonsurgical centers for postoperative rehabilitation and long-term follow-up. This supplement focuses on the clinical significance of upper extremity reconstruction, addressing issues related to the availability and choice for surgery, preoperative assessments, postoperative training paradigms, and appropriate outcome measures. Comprehensive intervention protocols are described in terms of dose, timing, specific activities, modalities, and related outcomes. Shared knowledge of current rehabilitation practice, as it relates to reconstructive surgery, can expand treatment options communicated to patients, increase the availability of postoperative muscle reeducation programs, and motivate long-term follow-up assessments.

Evaluation of a Task-Based Intervention After Tendon Transfer to Restore Lateral Pinch.

OBJECTIVE: To quantify changes in pinch force and brachioradialis (BR) activation after a task-based training program designed to improve pinch force after BR to flexor pollicis longus (FPL) transfer. DESIGN: One-group repeated-measures design compared pinch force and BR activation pre- and posttraining. Significant differences were tested with Wilcoxon signed-rank tests for pairwise comparisons at the P≤.05 level. SETTING: Testing occurred in a Veterans Affairs Medical Center research laboratory and training was in a home setting. PARTICIPANTS: Participants with cervical spinal cord injury (SCI) and previous BR to FPL transfer were enrolled in the study (N=8). Six patients completed the training program and posttraining measures. INTERVENTIONS: The 10-week training was a home program that included novel activities to increase BR activation and practice producing pinch force in a variety of upper limb postures. Participants were provided with the task-based training equipment and instructed to practice 3 times per week. MAIN OUTCOME MEASURES: Fine-wire electromyography of the transferred BR was recorded in maximum effort pinch force (N). Secondary measures included the strength and activation of the antagonist elbow extensor. RESULTS: Pinch force increased 3.7N (.38kg) and BR muscle activation increased 10% (P≤.05) after the training. There was no increase in elbow extension strength, but participants with previous posterior deltoid to triceps transfer achieved greater activation of the antagonist elbow extensor. CONCLUSIONS: The findings from this pilot study suggest that outcomes of tendon transfer and conventional therapy can be improved for patients with chronic cervical SCI.

Multicenter Survey of the Effects of Rehabilitation Practices on Pinch Force Strength After Tendon Transfer to Restore Pinch in Tetraplegia.

OBJECTIVE: To identify key components of conventional therapy after brachioradialis (BR) to flexor pollicis longus (FPL) transfer, a common procedure to restore pinch strength, and evaluate whether any of the key components of therapy were associated with pinch strength outcomes. DESIGN: Rehabilitation protocols were surveyed in 7 spinal cord injury (SCI) centers after BR to FPL tendon transfer. Key components of therapy, including duration of immobilization, participation, and date of initiating therapy activities (mobilization, strengthening, muscle reeducation, functional activities, and home exercise), were recorded by the patient's therapist. Pinch outcomes were recorded with identical equipment at 1-year follow-up. SETTING: Seven SCI rehabilitation centers where the BR to FPL surgery is performed on a routine basis. PARTICIPANTS: Thirty-eight arms from individuals with C5-7 level SCI injury who underwent BR to FPL transfer surgery (N=34). INTERVENTION: Conventional therapy according to established protocol in each center. MAIN OUTCOME MEASURES: The frequency of specific activities and their time of initiation (relative to surgery) were expressed as means and 95% confidence intervals. Outcome measures included pinch strength and the Canadian Occupational Performance Measure (COPM). Spearman rank-order correlations determined significant relations between pinch strength and components of therapy. RESULTS: There was similarity in the key components of therapy and in the progression of activities. Early cast removal was associated with pinch force (Spearman ρ=-.40, P=.0269). Pinch force was associated with improved COPM performance (Spearman ρ=.48, P=.0048) and satisfaction (Spearman ρ=.45, P=.0083) scores. CONCLUSIONS: Initiating therapy early after surgery is beneficial after BR to FPL surgery. Postoperative therapy protocols have the potential to significantly influence the outcome of tendon transfers after tetraplegia.

Measurement of Outcomes of Upper Limb Reconstructive Surgery for Tetraplegia.

Reconstructive arm/hand surgery for tetraplegia is performed to improve arm/hand function and therefore personal well-being for individuals who accept such elective surgeries. However, changes at an impairment level do not always translate into functional or quality of life changes. Therefore, multiple outcome tools should be used that incorporate sufficient responsiveness to detect changes in arm/hand function, activity and participation, and quality of life of the individuals involved. This narrative review aims to assist clinicians to choose the most appropriate tools to assess the need for reconstructive surgery and to evaluate its outcomes. Our specific objectives are (1) to describe aspects to consider when choosing a measure and (2) to describe the measures advised by an international therapist consensus group established in 2007. All advised measures are appraised in terms of the underlying construct, administration, and clinical relevance to arm/hand reconstructions. Essentially there are currently no criterion standard measures to evaluate the consequences of reconstructive arm/hand surgery. However, with judicious use of available measures it is possible to ensure the questions asked or tasks completed are relevant to the surgical reconstruction(s) undertaken. Further work in this field is required. This would be best met by immediate collaboration between 2 outcome's tool developers and by analysis of pre- and postoperative data already held in various international sites, which would allow further evaluation of the measures already in use, or components thereof.

Triceps Brachii in Incomplete Tetraplegia: EMG and Dynamometer Evaluation of Residual Motor Resources and Capacity for Strengthening.

BACKGROUND: Candidates for activity-based therapy after spinal cord injury (SCI) are often selected on the basis of manual muscle test scores and the classification of the injury as complete or incomplete. However, these scores may not adequately predict which individuals have sufficient residual motor resources for the therapy to be beneficial. OBJECTIVE: We performed a preliminary study to see whether dynamometry and quantitative electromyography (EMG) can provide a more detailed assessment of residual motor resources. METHODS: We measured elbow extension strength using a hand-held dynamometer and recorded fine-wire EMG from the triceps brachii muscles of 4 individuals with C5, C6, or C7 level SCI and 2 able-bodied controls. We used EMG decomposition to measure motor unit action potential (MUAP) amplitudes and motor unit (MU) recruitment and firing-rate profiles during constant and ramp contractions. RESULTS: All 4 subjects with cervical SCI (cSCI) had increased MUAP amplitudes indicative of denervation. Two of the subjects with cSCI had very weak elbow extension strength (<4 kg), dramatically reduced recruitment, and excessive firing rates (>40 pps), suggesting profound loss of motoneurons. The other 2 subjects with cSCI had stronger elbow extension (>6 kg), more normal recruitment, and more normal firing rates, suggesting a substantial remaining motoneuron population. CONCLUSIONS: Dynamometry and quantitative EMG may provide information about the extent of gray matter loss in cSCI to help guide rehabilitation strategies.

Adherence and perceptions of a home sports video gaming program in persons with spinal cord injuries: A pilot study.

OBJECTIVE: Sports video-gaming can facilitate increased activity levels in persons with limited exercise options. Understanding how persons with spinal cord injuries (SCI) participate in home-based video-gaming and its potential impact on maintaining or enhancing physical function remains largely unexplored. The purpose of this study was to evaluate adherence, perceptions, and potential physical effects of a home sports video-game program for persons with chronic SCI. PARTICIPANTS: Fourteen individuals with chronic SCI (9 tetraplegia, 5 paraplegia). DESIGN: This was a prospective study. Wii video-gaming systems that included four sports games were provided to participants for home use. Participants were instructed to play for 8 weeks 3-4 days/week. The video consoles recorded the time and number of sessions played. OUTCOME MEASURES: At baseline and at the conclusion of the program, measurements were made of upper extremity strength, perceived exertion, active heart rate, pain, balance, and a functional upper extremity (UE) test. The total time and number of sessions were compared to the prescribed game play as a measure of adherence. Scores from a self-reported survey were used to gauge participants' satisfaction and perceptions of their gaming experience. RESULTS: Overall mean gaming adherence was 85% during the first 4 weeks and 69% for the second 4 weeks. There were no significant changes in upper extremity strength, active heart rate, balance, pain, or functional UE test for either group. All of the participants rated video gaming as enjoyable and 85.7% perceived that it could be used as a form of exercise. CONCLUSION: The Wii sports home video-gaming intervention elicited overall high adherence rates and was well received by study participants indicating that it may have value as an adjunctive tool for increasing physical activity for individuals with SCI.

Calf stretching in non-weight bearing versus weight bearing.

Limited ankle dorsiflexion passive range of motion (DF PROM) has been associated with lower extremity overuse injuries. Therefore, clinicians often prescribe stretching exercises to increase ankle DF PROM. However, there is limited evidence to indicate if any particular gastrocnemius stretching exercise results in greater improvement in DF PROM. The aim of this study was to determine if gastrocnemius stretching in non-weight bearing (NWB) or weight bearing (WB) results in a greater increase of ankle DF PROM. 28 healthy volunteers, aged 18-55 years, who exhibited less than 10 degrees of ankle DF PROM completed the study. Participants were randomized into 2 stretching groups: NWB and WB. Both groups completed a 3-week home gastrocnemius stretching program, consisting of 5 repetitions held for 30 s each, 2 times daily. Participants' ankle DF PROM was measured with a blinded standard goniometer in NWB and WB positions before and after participation in a 3-week home gastrocnemius stretching program. Two 3-way mixed model ANOVAs demonstrated no significant difference in ankle DF PROM between the NWB and WB groups for either the NWB measurement condition (p=0.49) or WB measurement condition (p=0.86). Gastrocnemius stretching exercises performed in NWB or WB were equally effective in increasing ankle DF PROM.

Comparison of wrist and elbow stabilization following pinch reconstruction in tetraplegia.

PURPOSE: Individuals with spinal cord injuries resulting in tetraplegia may receive tendon transfer surgery to restore grasp and pinch function. These procedures often involve rerouting the brachioradialis (Br) and the extensor carpi radialis longus tendons volar to the flexion-extension axis of the wrist, leaving the extensor carpi radialis brevis (ECRB) muscle to provide wrist extension strength. The purpose of this study was to determine whether externally stabilizing the wrist after transfer procedures would improve the ability to activate the transferred Br and resulting pinch force, similar to the effect observed when the elbow is externally stabilized. METHODS: We used a one-way repeated-measures study design to determine the effect of 3 support conditions on muscle activation and lateral pinch force magnitude in 8 individuals with tetraplegia and previous tendon transfer surgeries. Muscle activation was recorded from Br and ECRB with intramuscular electrodes and from biceps and triceps muscles with surface electrodes. We quantified pinch strength with a 6-axis force sensor and custom grip. We recorded measurements in 3 support conditions: with the arm self-stabilized, with elbow stabilization, and with elbow and wrist stabilization. Pairwise differences were tested using Wilcoxon signed-rank tests. RESULTS: Maximum effort pinch force magnitude and Br activation were significantly increased in both supported conditions compared with the self-supported trials. The addition of wrist stabilization had no significant effect compared with elbow stabilization alone. CONCLUSIONS: A strong ECRB has adequate strength to extend the wrist, even after multiple transfers that contribute an additional flexion moment from strong activation of donor muscles. Anatomical and functional differences between the wrist and elbow musculature are important determinants for self-stabilizing joints proximal to the tendon transfer. The ability to increase Br activation and resulting pinch force may be determined, in part, by the individual's ability to develop new coordination strategies.

Changes in route of hysterectomy in Norway since introduction of robotic approach.

INTRODUCTION: From 2008, several Norwegian Health Trusts have acquired surgical robotic systems, and robotic hysterectomy accounted for 15 % of all hysterectomies performed in Norway in 2018. Robotic assisted hysterectomy is costly, and there is no evidence that the clinical outcome of robotic assisted hysterectomy is superior compared to the outcomes following other minimal invasive hysterectomies such as vaginal and laparoscopic hysterectomies. The objectives of this study were to describe the implementation of robotic hysterectomy and changes in other hysterectomy approaches, such as open abdominal, laparoscopic and vaginal hysterectomy in hospitals with and without robotic systems for hysterectomy. METHODS: Quantitative study based on hysterectomy data between 2010 to 2018 from the Norwegian Patient Registry. RESULTS: 9 out of 19 health trusts performed robotic assisted hysterectomy during the study period. The rate of abdominal hysterectomies declined during the study period, both in the health trusts with and without available surgical robotic systems. The rate of other minimally invasive hysterectomies also declined in some health trusts after the implementation of robotic assisted hysterectomy. DISCUSSION: Robotic hysterectomy has been implemented and is increasing in Norway without a thorough evaluation of the effect on patient safety and possible economic consequences. According to our findings, it appears that the implementation of robotic hysterectomy has not had a significant impact on the use of open abdominal hysterectomy. Although associated with increased costs and a lack of evidence of improved clinical outcomes for women, robotic hysterectomy has furthermore to some extent replaced other minimal invasive hysterectomies.

Toward Consensus in Assessing Upper Limb Muscle Strength and Pinch and Grip Strength in People With Tetraplegia Having Upper Limb Reconstructions.

OBJECTIVES: To reach agreement on standardized protocols for assessing upper limb strength and grip and pinch force for upper limb reconstructive surgery for tetraplegia. METHODS: Selected members of an expert panel composed of international therapists formed at the 2018 International Congress for Upper Limb Surgery for Tetraplegia conducted a literature review of current practice that identified gaps and inconsistencies in measurement protocols and presented to workshop attendees. To resolve discrepancies, a set of questions was presented to workshop attendees who voted electronically. Consensus was set at 75% agreement. RESULTS: For manual muscle testing, consensus was reached for using the Medical Research Council scale, without plus or minus, and the use of resistance through range when testing grade 4 and grade 5 strength. Pectoralis major and serratus anterior should be routinely tested, however there was no consensus on other shoulder muscles. Grip and pinch strength should be tested according to the American Society of Hand Therapists positioning. For grip strength, either the Jamar or Biometrics dynamometer expressed in kilograms should be used. For grip and pinch strength, three measurements should be performed at each testing. No consensus was reached on a device for pinch strength. CONCLUSION: This work is an important step to enable comparable data in the future. Further consensus methods will work toward developing more comprehensive guidelines in this population. Building international consensus for pre- and postoperative measures of function supports objective evaluation of novel therapies and interpretation of multicenter studies.

Upper limb muscle activation during sports video gaming of persons with spinal cord injury.

OBJECTIVE: Video gaming as a therapeutic tool has largely been studied within the stroke population with some benefits reported in upper limb motor performance, balance, coordination, and cardiovascular status. To date, muscle activation of upper limb muscles in persons with spinal cord injuries (SCI) has not been studied during video game play. In this paper, we provide descriptive and comparative data for muscle activation and strength during gaming for players with tetraplegia and paraplegia, as well as, compare these results with data from traditional arm exercises (ie, biceps curl and shoulder press) with light weights which are commonly prescribed for a home program. PARTICIPANTS: Fourteen individuals with chronic SCI (9 tetraplegia, 5 paraplegia). DESIGN: We measured upper limb muscle activation with surface electromyography (EMG) during Wii Sports video game play. Muscle activation was recorded from the playing arm during 4 selected games and normalized to a maximum voluntary contraction (MVC). OUTCOME MEASURES: Heart rate and upper limb motion were recorded simultaneously with EMG. Wilcoxon signed rank tests were used to analyze differences in muscle activation between participants with paraplegia versus tetraplegia and compare gaming with traditional arm exercises with light weights. A Friedman 2-way analysis of variance identified key muscle groups active during game play. RESULTS: Overall muscle activation across the games was not different between those with paraplegia and tetraplegia. Heart rate during video game play for tennis and boxing were on average 10 to 20 beats/minute above resting heart rate. The magnitude of EMG was relatively greater for traditional arm exercises with light weights compared with game play. CONCLUSION: The selected Wii games were able to elicit upper extremity muscle activation and elevated heart rates for individuals with SCI that may be used to target therapeutic outcomes.

Amplitude threshold criteria improve surface electrode specificity during walking and functional movements.

Contamination of electromyographic (EMG) data due to crosstalk in recordings from surface electrodes can lead to misinterpretation of results. The purpose of this study was to determine if removing a portion of the EMG signal normalized to a maximum voluntary contraction (MVC) would improve the specificity of surface electrode recordings. We hypothesized that setting an amplitude threshold to define when a muscle was active would remove that part of the myoelectric signal most likely to include crosstalk, without affecting the intensity or the onset and cessation times. Surface and intramuscular electrodes recorded signals from the same muscles of adults performing cyclic ankle movements and walking at self-selected speeds. Signals identified as crosstalk were eliminated when 15% and 18% of the amplitude of the normalized signal was removed and muscle timing or intensity was not significantly changed in most cases.

A comparison of gait with solid and hinged ankle-foot orthoses in children with spastic diplegic cerebral palsy.

This study compared the effects of solid and hinged ankle-foot orthoses (AFOs) on the gait of children with spastic diplegic cerebral palsy (CP) who ambulate with excessive ankle plantar flexion during stance. Twelve children with spastic diplegic CP wore no AFOs for an initial 2-week period, solid AFOs for 1 month, no AFOs for 2 weeks, and hinged AFOs for 1 month. Lower extremity muscle timing, knee and ankle joint motions, moments and powers, and temporal-distance characteristics were measured during ambulation for an initial barefoot baseline test, and with solid and hinged AFOs for the other two tests. Both orthoses increased stride length, reduced abnormal ankle plantar flexion during initial contact, midstance and terminal stance (TST), and increased ankle plantar flexor moments closer to normal during TST. Hinged AFOs increased ankle dorsiflexion at TST and increased ankle power generation during preswing (PSW) as compared to solid AFOs, and increased ankle dorsiflexion at loading compared to no AFOs. No other significant differences were found for the gait variables when comparing these orthoses. Either AFO could be used to reduce the excessive ankle plantar flexion without affecting the knee position during stance. The hinged AFO would be recommended to produce more normal dorsiflexion during TST and increased ankle power generation during PSW in children with spastic diplegic CP.

Effects of piracetam on regional cerebral blood flow and mental functions in patients with organic dementia.

The effects of piracetam (Nootropil, UCB6215) on mental functions and on regional cerebral blood flow (rCBF) were investigated in eight patients in the presenile age who displayed symptoms of moderate dementia. The double-blind crossover design included nine measurement occasions, each involving rCBF measurement by the 133-Xe inhalation method, ratings of symptoms of dementia, personality changes, and side effects, and a psychometric investigation. Three investigations were included in each of three treatment periods. The first investigation in a period was made without medication. Then either placebo or piracetam 4.8 g/day or 9.6 g/day was given during four weeks with measurements after 2 weekks and 4 weeks. There were intervals of 4 weeks without medication between the treatment periods. Piracetam had no significant effect on either mental functions or rCBF.

Addressing life style in primary health care.

The problem studied concerns how patients and physicians talk about and make use of information regarding patient life style in the daily practice of primary health care. The study has been carried out at two primary health care centers in central Sweden. Transcribed dialogues between 42 patients and 12 physicians have been used as a data corpus. The analyses concern the interactional patterns in the dialogues between patient and physician, how the interlocutors address life style and for what purposes. The results show a similarity between patients and physicians with respect to the extent to which they use the discourse space. However, salient differences were found in the following way: the physicians not only introduced and closed life style topics more frequently than the patients did, they also used what is referred to as an agenda driven strategy to introduce them. The patients, on the other hand, used an interactively anchored strategy. The patients, by taking the reference in the life world and by making use of the life style topics, present and articulate their identity. The physicians subsume life style issues under a medical framing of the patients' problem and they mainly address life style in order to construe a proto-typical patient rather than an individual.

Lifestyle in primary health care discourse.

This study is the first part of the project "Lifestyle Questions in Primary Health Care". The study aims at exploring how lifestyle enters into the health care discourse and what significance such factors are given in the clinical work. The particular problem thus concerns the extent to which lifestyle issues are brought up and attended to in the clinical encounters as well as in the medical records. The study was performed at two primary health care centres in central Sweden. The analyses are based on 42 transcribed consultations and on the medical records produced on the basis of these dialogues. The results show that lifestyle issues are given considerable attention in the primary health care encounter. Roughly one third of the discourse space is devoted to these kinds of topics, and the patients and doctors share the discourse space equally between them. There is also a high consistency between topics given space in the discussion and those that are entered into the medical records. The results also point to what could be conceived as a common discursive code between the health centres studied, indicating that there are similar communicative strategies for discussing lifestyle issues.

Lifestyle discussion in the provision of health care. An empirical study of patient-physician interaction.

The main issue explored is how patients and physicians communicate about lifestyle in the clinical encounter and what role this talk plays in terms of the outcome of the consultation. The data, collected at two primary health care centers, consist of 42 audiorecorded consultations. The analyses are based on these transcribed dialogues. Our study shows that communication about lifestyle issues is used as a source for determining what health care measures are relevant. Physicians provided a variety of types of information and explicit connections were made between lifestyle and the medical problem by physicians as well as patients. Within the process of reaching decisions on advice or treatment, two forms of interaction appeared referred to here as "paternalism" and "mutuality". In general, the results show that the physicians are very cautious about making explicit medical inferences concerning specific issues of the individual's lifestyle.

Variations in the gait of normal children. A graph applicable to the documentation of abnormalities.

The goal of much orthopaedic treatment of children is to improve their walking. To document the quantitative characteristics of walking, we devised graphic displays of speed, cadence, stride length, and body height on the basis of 2,416 observations of 324 children walking over a range of speeds. The gait graph is an uncomplicated tool for the clinician to use in the documentation and evaluation of gait in children. It also provides the means to relate the walking abilities of patients to the standards for normal children.

Towards a realistic biomechanical model of the thumb: the choice of kinematic description may be more critical than the solution method or the variability/uncertainty of musculoskeletal parameters.

A biomechanical model of the thumb can help researchers and clinicians understand the clinical problem of how anatomical variability contributes to the variability of outcomes of surgeries to restore thumb function. We lack a realistic biomechanical model of the thumb because of the variability/uncertainty of musculoskeletal parameters, the multiple proposed kinematic descriptions and methods to solve the muscle redundancy problem, and the paucity of data to validate the model with in vivo coordination patterns and force output. We performed a multi-stage validation of a biomechanical computer model against our measurements of maximal static thumbtip force and fine-wire electromyograms (EMG) from 8 thumb muscles in each of five orthogonal directions in key and opposition pinch postures. A low-friction point-contact at the thumbtip ensured that subjects did not produce thumbtip torques during force production. The 3-D, 8-muscle biomechanical thumb model uses a 5-axis kinematic description with orthogonal and intersecting axes of rotation at the carpometacarpal and metacarpophalangeal joints. We represented the 50 musculoskeletal parameters of the model as stochastic variables based on experimental data, and ran Monte Carlo simulations in the "inverse" and "forward" directions for 5000 random instantiations of the model. Two inverse simulations (predicting the distribution of maximal static thumbtip forces and the muscle activations that maximized force) showed that: the model reproduces at most 50% of the 80 EMG distributions recorded (eight muscle excitations in 5 force directions in two postures); and well-directed thumbtip forces of adequate magnitude are predicted only if accompanied by unrealistically large thumbtip torques (0.64+/-0.28Nm). The forward simulation (which fed the experimental distributions of EMG through random instantiations of the model) resulted in misdirected thumbtip force vectors (within 74.3+/-24.5 degrees from the desired direction) accompanied by doubly large thumbtip torques (1.32+/-0.95Nm). Taken together, our results suggest that the variability and uncertainty of musculoskeletal parameters and the choice of solution method are not the likely reason for the unrealistic predictions obtained. Rather, the kinematic description of the thumb we used is not representative of the transformation of net joint torques into thumbtip forces/torques in the human thumb. Future efforts should focus on validating alternative kinematic descriptions of the thumb.

A comparison of gait with solid, dynamic, and no ankle-foot orthoses in children with spastic cerebral palsy.

BACKGROUND AND PURPOSE: This study compared the effects of dynamic ankle-foot orthoses (DAFOs) with a plantar-flexion stop, polypropylene solid ankle-foot orthoses (AFOs), and no AFOs on the gait of children with cerebral palsy (CP). These orthoses were used to reduce the excessive ankle plantar flexion during the stance phase of gait. SUBJECTS AND METHODS: Ten children with spastic CP (6 with diplegia and 4 with hemiplegia) were tested after wearing no AFOs for an initial 2-week period, solid AFOs for 1 month, no AFOs for an additional 2 weeks, and DAFOs for 1 month. The effects of the two orthoses and no AFOs on lower-extremity muscle timing, joint motions, and temporal-distance characteristics were compared. RESULTS: Both orthoses increased stride length, decreased cadence, and reduced excessive ankle plantar flexion when compared with no orthoses. No differences were found for the gait variables when comparing the two orthoses. CONCLUSION AND DISCUSSION: Based on the data, the authors believe that although both orthoses would be recommended for children with spastic CP and excessive ankle plantar flexion during stance, additional individual factors should be considered when selecting either orthosis.