The Efficacy of Ankle-Foot Orthoses on Improving the Gait of Children With Diplegic Cerebral Palsy: A Multiple Outcome Analysis  Andrew J. Ries, MS, Tom F. Novacheck, MD, Michael H. Schwartz, PhD  PM&R  Volume 7, Issue 9, Pages 922-929 (September 2015) DOI: 10.1016/j.pmrj.2015.03.005 Copyright © 2015 American Academy of Physical Medicine and Rehabilitation Terms and Conditions

Figure 1 Changes in outcome between walking barefoot (BF) and with an ankle-foot orthosis (AFO). The shaded areas represent change less than the minimal clinical important difference (MCID). The solid vertical lines represent mean change and the dashed lines represent zero change. (A) Average Gait Deviation Index (GDI) improved slightly (statistically but not clinically). For the MCID of +5, 27% of limbs had clinically meaningful improvements, whereas 15% clinically worsened. (B) Mean ankle Gait Variable Score (GVS) did not change with an AFO. For the MCID of 1.5°, 31% of limbs experienced meaningful improvements, whereas 42% of limbs clinically worsened. (C) Mean knee GVS change reflected minimal influence on knee function from an AFO. With an MCID of 3.4°, only 10% of limbs received a clinical benefit, whereas 11% of limbs experienced a meaningful worsening of knee function. (D) Mean nondimensional (ND) speed was clinically improved. For the MCID of 0.039, 48% of limbs clinically improved, whereas only 6% worsened. (E) Mean ND step length was clinically improved. For the MCID of 0.044, 76% of limbs clinically improved, whereas only 5% worsened. PM&R 2015 7, 922-929DOI: (10.1016/j.pmrj.2015.03.005) Copyright © 2015 American Academy of Physical Medicine and Rehabilitation Terms and Conditions

Figure 2 Significant main effects for ankle-foot orthosis (AFO) design and ambulation type on outcomes. (A) Effect of AFO design on ankle Gait Variable Score (GVS). (B) Effect of AFO design on nondimensional (ND) speed. (C) Effect of ambulation type on Gait Deviation Index (GDI). The asterisk and line above the plots identify significant differences between groups as determined by Tukey's honestly significant difference test at α = .05. Error bars represent the 95% confidence interval of the actual mean change in outcome for each group, and dashed lines represent the minimal clinical important difference (MCID) levels for improvement (the MCID for GDI is off the plot at +5). HAFO = hinged joint ankle-foot orthosis; PLS = posterior leaf spring; SAFO = solid ankle-foot orthosis. PM&R 2015 7, 922-929DOI: (10.1016/j.pmrj.2015.03.005) Copyright © 2015 American Academy of Physical Medicine and Rehabilitation Terms and Conditions

Figure 3 General gait quality metrics. (A) There was a significant interaction between barefoot (BF) Gait Deviation Index (GDI) and ambulation type. Independent ambulators had the most sensitivity to BF GDI, whereas little effect was observed for dependent ambulators. (B) The main effects of ankle Gait Variable Score (GVS) and knee GVS are shown (no significant interactions were observed for either). There was a strong main effect of BF ankle GVS and change in ankle GVS (r2 = 0.45). The main effect of BF knee GVS and change in knee GVS was low (r2 = 0.15). PM&R 2015 7, 922-929DOI: (10.1016/j.pmrj.2015.03.005) Copyright © 2015 American Academy of Physical Medicine and Rehabilitation Terms and Conditions

Figure 4 Spatiotemporal metrics. (A) The main effect for barefoot (BF) nondimensional (ND) speed on change in ND speed is apparent. There was a significant interaction between ankle-foot orthosis (AFO) design and BF ND speed. The solid AFO (SAFO) was slightly more effective at improving walking speed when speed was slower than the typical ND walking speed measured for unimpaired control subjects (<0.363). However, the SAFO group had greater negative speed changes for normal or fast walkers because of the larger interaction. (B) The main effect of BF ND step length on change in ND step length is shown (there were no significant interactions for ND step length). HAFO = hinged joint ankle-foot orthosis; PLS = posterior leaf spring. PM&R 2015 7, 922-929DOI: (10.1016/j.pmrj.2015.03.005) Copyright © 2015 American Academy of Physical Medicine and Rehabilitation Terms and Conditions