Orthotic braces are designed to support, stabilize and correct dysfunctions of the lower limbs; but fitting such braces to a child with limited mobility goes beyond those cold facts, opening doors to new possibilities, inspiring greater confidence and often initiating a dramatic life change.
No child wants to be “different”—and a well-chosen and properly fitted orthosis can serve as something of an equalizer for a child with cerebral palsy, muscular dystrophy or spina bifida—minimizing those differences as much as possible and allowing the child to follow a more natural process of participating, competing and supporting/partnering with peers rather than feeling excluded.
Especially where ambulation is concerned, it’s important for a child to feel they are “keeping up with” others; and in many cases, a lower limb orthosis such as an AFO (ankle foot orthosis) helps to serve this need.
Steve Fisher, a certified and licensed orthotist at Snell Prosthetic & Orthotic Laboratory in Little Rock, notes that while some children initially object to wearing an AFO that makes them look different, their attitudes can quickly change once they recognize the benefits.
“Soon these children actually want to wear their AFOs. I’ve had parents tell me the kids will hold the braces up for the parents and ask for them to be put on, because they’re more mobile with the braces on, and they realize that.”
AFOs not only enable greater mobility and confidence through the support they provide, they may also provide the foundation for improvement. Depending on the commitment and determination of the patient, in many cases truly significant and inspiring improvement is possible.
Fisher shares the story of a young patient with cerebral palsy who experienced muscular contracture that caused his feet to become rigid and uncontrollable—a condition known as “high tone.” The contracture caused the patient to walk on his toes, even when wearing the prescribed DAFO (dynamic ankle foot orthosis)—a brace that includes tone-reducing features in addition to the basic foot support a traditional AFO offers.
His goal was to be able to walk across the stage at graduation to receive his diploma, reports Fisher, part of a rehab team that encouraged him to do a program of exercises to stretch the heel cord, allowing him to lift his toes more freely.
“He worked hard for six months, and not only was he able to reach his goal on graduation day, he was also able to reduce his dependency on the AFO and switched to a shorter design that provided less support. And he also learned to drive a car!
“This young man who wanted to become more independent is now going to college. Through his efforts and hard work he reached his goal—a shorter brace. It’s possible he will outgrow the need for a brace entirely.”
Fitting a variety of conditions
AFOs are designed to treat a variety of conditions, from major to relatively minor. “The choice depends on the diagnosis of the patient,” Fisher explains. “A child with spina bifida is going to need a different kind of AFO than a child with different issues. Kids with cerebral palsy often have high tone, so physicians typically prescribe DAFOs that reduce tone and help to stop them pointing their toes all the time. With pointed toes their heel cord gets tight and when they stand up, they have to stand on their tiptoes because they can’t get their heels down. The DAFO is designed primarily to reduce the tone and hold their foot in a good neutral position.”
Children with low tone fall at the opposite end of the spectrum, where pronation (commonly referred to as fallen arches or flat feet) is the threat, Fisher says. “In this case, their muscles don’t have enough tone—they’re relaxed too much and they can fall into pronation, which does not allow them to support their weight comfortably.”
Children with spina bifida often require an AFO applied in combination with a reciprocating gait orthosis (RGO) that provides essential back support and sometimes enables the child to walk. “The RGO reaches up above the waist, so it helps them stand, which is going to help their bones get stronger from weight bearing.”
Some conditions change as the child grows. “Sometimes the child will have high tone when they’re young, and as they get older it decreases, allowing them to go to a shorter brace—and sometimes they can get out of braces entirely. With cerebral palsy, function can certainly improve with age; the muscles benefit from muscle memory and they start walking better. After a lot of physical therapy, they can progress like our graduate who walked to accept his diploma,” Fisher notes.
With muscular dystrophy, on the other hand, muscles can weaken to the point where they require support; often they deteriorate further and the patient must begin using a wheelchair. “In this case,” says Fisher, “AFOs can keep them up and walking as long as possible; later, there are AFOs they can wear in the wheelchair to keep their feet in a neutral position which prevents the muscles from tightening and deforming the feet, and thus preserves range of motion for potential future weight bearing.”
Some braces, such as those designed to stretch the heel cord and restore range of motion, are designed for limited wear—during inactive periods such as sleep or for one-hour periods at school. Walking AFOs are made to reduce tone and hold the child’s feet in a neutral position so they can walk properly through heel strike and toe off; some enable active sports participation.
“Kids with pronation issues, including children with Down syndrome, are usually fitted with a shorter brace called a supra malealor orthosis or SMO. It reaches to just above the ankle, and fits comfortably inside their shoes, holding the arch up and controlling the heel to prevent a flat foot,” says Fisher, who fits orthoses and makes necessary adjustments for most of his small patients during school visits —a convenience appreciated by working parents.
DAFOs come in a range of sizes and designs, some with names sure to tickle a child’s imagination: The Leap Frog, Bunny, and Kangaroo, as well as the tone-reducing Hot Dog and the Chipmunk—which defied Darwin by evolving from a Pollywog!
To be safe and effective, all braces should be selected and fitted by a trained and licensed orthotist, who will instruct the child and parents regarding their correct use, including specific guidance regarding proper care and maintenance of the braces.