Influence of ankle-foot orthoses on gait symmetry in children with hemiplegic cerebral palsy: A prospective, cross-sectional study

Robert Staszkiewicz; Anna Strus

doi:10.37190/abb/220649

.blurhash-client-img { display: none !important; }

Influence of ankle-foot orthoses on gait symmetry in children with hemiplegic cerebral palsy: A prospective, cross-sectional study

Acta of Bioengineering and Biomechanics

Volume 28 (2026): Issue 1 (March 2026)

By: Robert Staszkiewicz and Anna Strus

Open Access

|Oct 2026

Abstract

Purpose

The main objective of the study was to analyse gait kinematics in terms of symmetry among groups of children with hemiplegic cerebral palsy (CP).

Material and methods

The study was conducted using the BTS SMART three-dimensional (3D) gait analysis optoelectronic system. Passive reflective markers were placed on subjects’ bodies in accordance with the Davis protocol. The study involved 43 children, aged 7 years. Group 1 (n = 18) comprised patients not using any orthopaedic equipment. Group 2 (n = 14) consisted of children using a unilateral ankle-foot orthosis on the affected side. Group 3 (n = 11) included children using bilateral ankle-foot orthoses.

Results

Improvement in gait symmetry was observed in orthosed children, and the majority of changes were significant (p < 0.05). Thus, it appears that this type of orthopaedic equipment affects not only the ankle joint, but also higher levels of the biokinematic chain.

Conclusions

In accordance with the results, it was shown that in patients using bilateral ankle-foot orthoses, a more positive effect of the described phenomena could be expected.

References

Bax, M., Goldstein, M., Rosenbaum, P., Leviton, A., Paneth, N., Dan, B., et al., Proposed definition and classification of cerebral palsy. Dev. Med. Child. Neurol., 2005, 47(8): 571–576, 10.1017/s001216220500112x.
Open DOI Search in Google Scholar Back to article
Stockman, J., Eggertsdóttir, G., Gaston, M.S., Jeglinsky-Kankainen, I., Hollung, S.J., Nordbye-Nielsen, K., et al., Ankle-foot orthoses among children with cerebral palsy: a cross-sectional population-based register study of 8,928 children living in Northern Europe, BMC Musculoskelet. Disord., 2023, 24(1): 443, 10.1186/s12891-023-06554-z.
Open DOI Search in Google Scholar Back to article
Vitrikas, K., Dalton, H., Breish, D., Cerebral palsy: An overview, Am. Fam. Physician, 2020, 101(4): 213–220.
Search in Google Scholar Back to article
Krägeloh-Mann, I., Cans, C., Cerebral palsy update, Brain Dev., 2009, 31: 537–544, 10.1016/j.braindev.2009.03.009.
Open DOI Search in Google Scholar Back to article
Hsue, B.J., Miller, F., Su, F.C., The dynamic balance of the children with cerebral palsy and typical developing during gait. Part I: Spatial relationship between COM and COP trajectories, Gait. Posture., 2009, 29: 465–470, 10.1016/j.gaitpost.2008.11.007.
Open DOI Search in Google Scholar Back to article
Wang, X., Wang, Y. Gait analysis of children with spastic hemiplegic cerebral palsy, Neural Regen. Res., 2012, 7(20): 1578–1584, 10.3969/j.issn.1673-5374.2012.20.008.
Open DOI Search in Google Scholar Back to article
Dong, V.A., Fong, K.N., Chen, Y.F., Tseng, S.S., Wong, L.M., Remind-to-move’ treatment versus constraint-induced movement therapy for children with hemiplegic cerebral palsy: a randomized controlled trial, Dev. Med. Child. Neurol., 2017, 59(2): 160–167, 10.1111/dmcn.13216.
Open DOI Search in Google Scholar Back to article
Harlaar, J., Brehm, M., Becher, J.G., Bregman, D.J., Buurke, J., Holtkamp, F., et al., Studies examining the efficacy of ankle foot orthoses should report activity level and mechanical evidence, Prosthet. Orthot. Int., 2010, 34(3): 327–335, 10.3109/03093646.2010.504977.
Open DOI Search in Google Scholar Back to article
Buckon, C.E., Thomas, S.S., Jakobson-Huston, S., Sussman, M., Aiona, M., Comparison of three ankle-foot orthosis configurations for children with spastic hemiplegia. Dev. Med. Child. Neurol., 2001, 43(6): 371–378, 10.1017/s0012162201000706.
Open DOI Search in Google Scholar Back to article
Thompson, N.S., Taylor, T.C., McCarthy, K.R., Cosgrove, A.P., Baker, R.J., Effect of a rigid ankle-foot orthosis on hamstring length in children with hemiplegia, Dev. Med. Child. Neurol., 2002, 44(1): 51–57, 10.1017/s0012162201001657.
Open DOI Search in Google Scholar Back to article
Schweizer, K., Brunner, R., Romkes, J., Upper body movements in children with hemiplegic cerebral palsy walking with and without an ankle-foot orthosis, Clin. Biomech. (Bristol), 2014, 29(4): 387–394, 10.1016/j.clinbiomech.2014.02.005.
Open DOI Search in Google Scholar Back to article
Miccinilli, S., Santacaterina, F., Della Rocca, R., Sterzi, S., Bressi, F., Bravi, M., Efficacy of lower limb orthoses in the rehabilitation of children affected by cerebral palsy: A systematic review, Children (Basel, Switzerland), 2024, 11(2): 212, 10.3390/children11020212.
Open DOI Search in Google Scholar Back to article
Pourhosseingholi, E., Farahmand, B., Bagheri, A., Kamali, M., Saeb, M., Efficacy of different techniques of AFO construction for hemiplegia patients: A systematic review, Med. J. Islam. Repub. Iran., 2019, 33: 50, 10.34171/mjiri.33.50.
Open DOI Search in Google Scholar Back to article
Ridgewell, E., Dobson, F., Bach, T., Baker, R., A systematic review to determine best practice reporting guidelines for AFO interventions in studies involving children with cerebral palsy, Prosthet. Orthot. Int., 2010, 34(2): 129–145, 10.3109/03093641003674288.
Open DOI Search in Google Scholar Back to article
Delgado, M.R., Tilton, A., Russman, B., Benavides, O., Bonikowski, M., Carranza, J., et al., Abobotulinumtoxin A for Equinus Foot Deformity in Cerebral Palsy: A Randomized Controlled Trial, Pediatrics, 2016, 137(2): 20152830, 10.1542/peds.2015-2830.
Open DOI Search in Google Scholar Back to article
Surana, B.K., Ferre, C.L., Dew, A.P., Brandao, M., Gordon, A.M., Moreau, N.G. Effectiveness of Lower-Extremity Functional Training (LIFT) in young children with unilateral spastic cerebral palsy: A randomized controlled trial, Neurorehabil Neural Repair., 2019, 33(10): 862–872, 10.1177/1545968319868719.
Open DOI Search in Google Scholar Back to article
Domagalska-Szopa, M., Szopa, A., Czamara, A., Dependence of Gait Deviation on Weight-Bearing Asymmetry and Postural Instability in Children with Unilateral Cerebral Palsy. PLoS One, 2016, 11(10): 0165583, 10.1371/journal.pone.0165583.
Open DOI Search in Google Scholar Back to article
Zimmermann, R., Poschmann, M., Altschuck, N., Bauer, C., von Pfeil, D., Bernius, P., et al., Influence of the percutaneous myofasciotomy on gait of children with spastic cerebral palsy - A short term, retrospective controlled analysis, Gait Posture, 2023, 104: 159–164, 10.1016/j.gaitpost.2023.06.023.
Open DOI Search in Google Scholar Back to article
Pavão, S.L., Nunes, G.S., Santos, A.N., Rocha, N.A., Relationship between static postural control and the level of functional abilities in children with cerebral palsy. Braz. J. Phys. Ther., 2014, 18(4): 300–307, 10.1590/bjpt-rbf.2014.0056.
Open DOI Search in Google Scholar Back to article
Ibrahim, N.M., Abbass, M.E., Weight distribution asymmetry in relation to walking speed in children with spastic cerebral palsy, Afr. Health Sci., 2022, 22(2): 565–572, 10.4314/ahs.v22i2.65.
Open DOI Search in Google Scholar Back to article
Elnaggar, R., The magnitude of temporal–spatial gait asymmetry is related to the proficiency of dynamic balance control in children with hemiplegic cerebral palsy: An analytical inquiry, Symmetry, 2024, 16: 1274, 10.3390/sym16101274.
Open DOI Search in Google Scholar Back to article
Staszkiewicz, R., Strus, A., Symmetry of body posture among children with hemiplegic cerebral palsy using Ankle Foot Orthoses (AFO): A case – control study, Acta Bioeng. Biomech., 2025, 27(2): 51–60, 10.37190/abb/205649.
Open DOI Search in Google Scholar Back to article
Patrick, J.H., Use of movement analysis in understanding abnormalities of gait in cerebral palsy, Arch. Dis. Child., 1991, 66: 900–903, 10.1136/adc.66.7.900.
Open DOI Search in Google Scholar Back to article
Rethlefsen, S.A., Blumstein, G., Kay, R.M., Dorey, F., Wren, T.A., Prevalence of specific gait abnormalities in children with cerebral palsy revisited: influence of age, prior surgery, and Gross Motor Function Classification System level, Dev. Med. Child. Neurol., 2017, 59(1): 79–88, 10.1111/dmcn.13205.
Open DOI Search in Google Scholar Back to article
Schwartz, M.H., Rozumalski, A., The gait deviation index: A new comprehensive index of gait pathology. Gait Posture, 2008, 28(3): 351–357, 10.1016/j.gaitpost.2008.05.001.
Open DOI Search in Google Scholar Back to article
de Morais Filho, M.C., Fujino, M.H., Kawamura, C.M., Lopes, J., Przysiada, L., Antunes Silva, M.E., Gait patterns in hemiplegic cerebral palsy: Is it time for a new classification? Gait Posture, 2025, 120: 40–45, 10.1016/j.gaitpost.2025.03.026.
Open DOI Search in Google Scholar Back to article
Salazar-Torres, J., Church, C., Miller, F., Lennon, N., Howard, J.J., Shields, T., et al., Gait pattern differences in unilaterally affected children with cerebral palsy and children with acquired brain insult, Gait Posture, 2025, 115: 116–121, 10.1016/j.gaitpost.2024.10.022.
Open DOI Search in Google Scholar Back to article
Davis, R.B., Reflections on clinical gait analysis, J. Electromyogr. Kinesiol., 1997, 7(4): 251–257, 10.1016/S1050-6411(97)00008-4
Open DOI Search in Google Scholar Back to article
Donno, L., Monoli, C., Frigo, C.A., Galli, M., Forward and Backward Walking: Multifactorial Characterization of Gait Parameters, Sensors (Basel, Switzerland), 2023, 23(10): 4671, 10.3390/s23104671.
Open DOI Search in Google Scholar Back to article
Tsitlakidis, S., Horsch, A., Schaefer, F., Westhauser, F., Goetze, M., Hagmann, S., et al., Gait Classification in Unilateral Cerebral Palsy, J. Clin. Med., 2019, 8(10): 1652, 10.3390/jcm8101652.
Open DOI Search in Google Scholar Back to article
Chakraborty, S., Nandy, A., Kesar, T.M., Gait deficits and dynamic stability in children and adolescents with cerebral palsy: A systematic review and meta-analysis, Clin. Biomech. (Bristol), 2020, 71: 11–23, 10.1016/j.clinbiomech.2019.09.005
Open DOI Search in Google Scholar Back to article
Herzog, W., Nigg, B.M., Read, L.J., Olsson, E., Asymmetries in ground reaction force patterns in normal human gait, Med. Sci. Sports Exerc., 1989, 21(1): 110–114, 10.1249/00005768-198902000-00020.
Open DOI Search in Google Scholar Back to article
Forczek, W., Staszkiewicz, R., An evaluation of symmetry in the lower limb joints during the able-bodied gait of women and men, J. Hum. Kinet., 2012, 35: 47–57, 10.2478/v10078-012-0078-5.
Open DOI Search in Google Scholar Back to article
Cohen, J., Cohen, P., West, S., Aiken, L.S., Applied multiple regression/correlation analysis for the behavioural sciences, 3rd Edn. Routledge: New York, 2003.
Search in Google Scholar Back to article
Goeman, J.J., Solari, A., Multiple hypothesis testing in genomics, Stat. Med., 2014, 33(11): 1946–1978, 10.1002/sim.6082.
Open DOI Search in Google Scholar Back to article
Novak, I., Morgan, C., Fahey, M., Finch-Edmondson, M., Galea, C., Hines, A., et al., State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr. Neurol. Neurosci. Rep., 2020, 20(2): 3, 10.1007/s11910-020-1022-z.
Open DOI Search in Google Scholar Back to article
Fujita, H., Fusagawa, H., Nishibu, H., Nosaka, T., Matsuyama, T., Iba, K., et al., Motion analysis and surgical results of anterior transfer of flexor hallucis longus for equinovarus gait in children with hemiplegia, J. Orthop. Sci., 2021, 26(3): 441–447, 10.1016/j.jos.2020.05.001.
Open DOI Search in Google Scholar Back to article
Balaban, B., Yasar, E., Dal, U., Yazicioglu, K., Mohur, H., Kalyon, T.A., The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy, Disabil. Rehabil., 2007, 29(2): 139–144, 10.1080/17483100600876740.
Open DOI Search in Google Scholar Back to article
Engsberg, J.R., Ross, S.A., Olree, .S., Park, T.S., Ankle spasticity and strength in children with spastic diplegic cerebral palsy. Dev. Med. Child. Neurol., 2000, 42(1): 42–47, 10.1017/s0012162200000086.
Open DOI Search in Google Scholar Back to article
Aboutorabi, A., Arazpour, M., Ahmadi Bani, M., Saeedi, H., Head, J.S., Efficacy of ankle foot orthoses types on walking in children with cerebral palsy: A systematic review, Ann. Phys. Rehabil. Med., 2017, 60(6): 393–402, 10.1016/j.rehab.2017.05.004, PMID: 28713039.
Open DOI Search in Google Scholar Back to article
Rasmussen, H.M., Pedersen, N.W., Overgaard, S., Hansen, L.K., Dunkhase-Heinl, U., Petkov, Y., et al., Gait analysis for individually tailored interdisciplinary interventions in children with cerebral palsy: a randomized controlled trial. Dev. Med. Child. Neurol., 2019, 61(10): 1189–1195, 10.1111/dmcn.14178.
Open DOI Search in Google Scholar Back to article
Lidbeck, C.M., Gutierrez-Farewik, E.M., Broström, E., Bartonek, Å, Postural orientation during standing in children with bilateral cerebral palsy, Pediatr. Phys. Ther., 2014, Summer, 26(2): 223–229, 10.1097/PEP.0000000000000025.
Open DOI Search in Google Scholar Back to article
Pohl, M., Mehrholz, J., Immediate effects of an individually designed functional ankle-foot orthosis on stance and gait in hemiparetic patients, Clin. Rehabil., 2006, 20(4): 324–330, 10.1191/0269215506cr951oa.
Open DOI Search in Google Scholar Back to article
Jagadamma, K.C., Coutts, F.J., Mercer, T.H., Herman, J., Yirrell, J., Forbes, L., et al., Optimising the effects of rigid ankle foot orthoses on the gait of children with cerebral palsy (CP) - an exploratory trial, Disabil. Rehabil. Assist. Technol., 2015, 10(6): 445–451, 10.3109/17483107.2014.908244.
Open DOI Search in Google Scholar Back to article
Hayek, S, Hemo, Y, Chamis, S, Bat, R., Segev, E., Wientroub, S., et al. The effect of community-prescribed ankle–foot orthoses on gait parameters in children with spastic cerebral palsy. J. Child. Orthop., 2007;1(6):325–332, 10.1007/s11832-007-0055-z.
Open DOI Search in Google Scholar Back to article
Melanda, A.G., Pauleto, A.C., Iucksch, D.D., Cunha, R., Smaili, S.M., Results of orthoses used on ambulatory patients with bilateral cerebral palsy, Acta Ortop. Bras., 2020, 28(3): 137–141, 10.1590/1413-785220202803228922.
Open DOI Search in Google Scholar Back to article
Leonard, R., Sweeney, J., Damiano, D., Bjornson, K., Ries, J., Effects of orthoses on standing postural control and muscle activity in children with cerebral palsy, Pediatr. Phys. Ther., 2021, 33(3): 129–135, 10.1097/PEP.0000000000000802.
Open DOI Search in Google Scholar Back to article
Bahar-Özdemir, Y., Ünal-Ulutatar, Ç, Karali-Bingül, D., Karadağ-Saygı, E., Efficacy of foot-ankle orthosis on balance for children with hemiplegic cerebral palsy: An observational study, Turk. J. Phys. Med. Rehabil., 2021, 67(3): 336–343, 10.5606/tftrd.2021.5175.
Open DOI Search in Google Scholar Back to article
Liu, X.C., Embrey, D., Tassone, C., Zvara, K., Brandsma, B., Lyon, R., et al., Long-term effects of orthoses use on the changes of foot and ankle joint motions of children with spastic cerebral palsy, PM R., 2018, 10(3): 269–275, 10.1016/j.pmrj.2017.08.438.
Open DOI Search in Google Scholar Back to article
Lucareli, P.R., Lima Mde, O., Lucarelli, J.G., Lima, F.P., Changes in joint kinematics in children with cerebral palsy while walking with and without a floor reaction ankle–foot orthosis, Clinics (Sao Paulo, Brazil), 2007, 62(1): 63–68, 10.1590/S1807-59322007000100010.
Open DOI Search in Google Scholar Back to article
Molteni, L.E., Andreoni, G., Comparing the accuracy of markerless motion analysis and optoelectronic system for measuring gait kinematics of lower limb. Bioengineering (Basel, Switzerland), 2025, 12, 424, 10.3390/bioengineering12040424.
Open DOI Search in Google Scholar Back to article
Rigoldi, C., Molteni, E., Rozbaczylo, C., Morante, M., Albertini, G., Bianchi, A.M., et al., Movement analysis and EEG recordings in children with hemiplegic cerebral palsy, Exp. Brain Res., 2012, 223: 517–524, 10.1007/s00221-012-3278-2.
Open DOI Search in Google Scholar Back to article
Francia, C., Motta, F, Donno, L., et al., Validation of a MediaPipe System for Markerless Motion Analysis During Virtual Reality Rehabilitation. In: De Paolis L., Arpaia P., Sacco M. (eds) Extended Reality. XR Salento 2024. Lecture Notes in Computer Science, vol 15029, Springer, Cham.
Search in Google Scholar Back to article