LETTER TO THE EDITOR

ANKLE-FOOT ORTHOSES MANAGEMENT IN CHILDREN WITH SPASTIC DIPLEGIA Re: Day vs. Day-Night Use of Ankle-Foot Orthoses in Young Children with Spastic Diplegia To the Editor: Overall, Zhao et al.1 are to be commended on thoroughly conducting their study, comparing the effectiveness of day wearing vs. day-night wearing of hinged ankle-foot orthoses (AFOs) in children with spastic diplegia. Through this research, the efficacy of outcomes demonstrated a decreased risk of bias by the authors’ ability to limit their sample population to children with similar etiology, similar functional capabilities, and similar diagnosis of cerebral palsy.1 By researching day vs. day-night wearing of hinged AFOs with children with spastic diplegia, coupled with physical therapy sessions 5 days a week for 8 wks, these researchers were able to conclude that the day-wearing group demonstrated more significant improvement in Gross Motor Function Measure scores.1 Although their research was thorough, it seemed to be limited by some significant aspects that could be considered corresponding influences that affected the overall outcomes. The contributing factors that might be relevant, but overlooked, are the limited age range of the sample population used for the study, the limited information on what specific interventions were done during the therapy sessions, and whether the interventions were exactly the same for each participant. Although the authors briefly mentioned these limitations in their conclusion, there is still a need to further expand upon these limitations noted within this study. First, one aspect of this research study that really stood out was the consistency of the sample population. The researchers did an excellent job maintaining similar etiology with the 112 participants and used a stratified randomization system to separate them into the two comparison groups; however, they seemed to have limited themselves by researching such a condensed age range of children. These researchers have admitted to this limitation and further noted that because of the young age, muscle tone is not yet stable during ambulatory and functional mobility tasks.1 Other studies that have been done regarding AFO management in individuals with cerebral palsy have broadened their age ranges to include the preteen years because of increased muscle strength and joint stability in the lower extremities.2 With a wider age range, the chances of finding individuals with increased functional mobility and ambulation during their lifespan doubles and sometimes triples. This, in turn, gives the researcher more opportunity to determine the effectiveness of the AFOs on different aspects of functional mobility and ambulation in later stages of life. Finally, it was never clearly identified what specific interventions were done during the physical therapy sessions and if every participant followed the same protocol. The www.ajpmr.com

different types of therapies that were offered included, hydrotherapy, neurodevelopmental treatment, and neuromuscular electrical stimulation1; however, it was not clarified if the children received the same exact therapy interventions every therapy session. There is cause to believe that the outcomes could have been skewed if the children received different therapies during their therapy sessions in those 8 wks. This is due to the fact that each of the different therapies focused on different functional outcomes. For example, hydrotherapy uses water as a therapeutic agent to help treat illness,3 whereas neurodevelopmental treatment uses techniques to influence more normal movement patterns and decrease abnormal reflex activation,4 and neuromuscular electrical stimulation uses an electrical stimulus to complete muscle reeducation and prevent atrophy.3 Therefore, it stands to reason that if the children received different interventions, the outcomes could have varied greatly. It is because of these limitations, the limited age range, and the limited information on therapy sessions and their protocol that the need for further research is encouraged. Despite these possible confounding influences to the outcomes and limitations of this study, the researchers did a due service to the healthcare profession by researching such an important and informative topic. It is imperative that the importance and impact that AFOs have on individuals with cerebral palsy are understood because of the influence these have on everyday functional activities. As today’s current healthcare professions continue to change and grow, there is a need for further research to expand knowledge of beneficial interventions and best practice for individuals in need. Overall, this randomized control trial was very compelling and important research for all related healthcare professions and was found to be extremely useful and informative. REFERENCES 1. Zhao X, Xiao N, Li H, et al: Day vs. day-night use of ankle-foot orthoses in young children with spastic diplegia: A randomized controlled study. Am J Phys Med Rehabil 2013;92:905Y11 2. Chisholm A, Perry S: Ankle-foot orthotic management in neuromuscular disorders: Recommendations for future research. Disabil Rehabil Assist Technol 2012;7:437Y49 3. Bracciano A: Physical agent modalities, in: Radomski M.V., Latham C.T. (eds): Occupational Therapy for Physical Dysfunction, 6th ed. Philadelphia, PA, Lippincott Williams & Wilkins, 2008, pp. 543Y71 4. Levit K: Optimizing motor behavior using the Bobath approach, in Radomski M.V., Latham C.T. (eds): Occupational Therapy for Physical Dysfunction, 6th ed. Philadelphia, PA, Lippincott Williams & Wilkins, 2008, pp. 643Y66

JaMae’ Van Eeuwen Masters in Occupational Therapy Utica College, Utica, NY DOI: 10.1097/PHM.0000000000000072

Letter to the Editor Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Ankle-foot orthoses management in children with spastic diplegia: re: day vs. day-night use of ankle-foot orthoses in young children with spastic diplegia.

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