Equipment

In looking at children with cerebral palsy and assistive devices, the Gross Motor Function Classification System (GMFCS) is a good predictor of the amount of assistance required both in physical assistance and in assistive devices with children at higher levels requiring more devices or personal help, especially at levels IV and V.

Orthoses/Braces
Orthoses (braces) are used for many children with cerebral palsy. They are used for hands, feet and for the trunk. Basically, there are two reasons for using them: positioning and enhancing function.

Ankle/Foot Orthoses (AFO)
Orthoses for the foot and leg can be divided into four types. The first type controls the heel and foot position; these basically keep the feet from rolling over to the inside or to the outside and keep the ankle in the middle. These braces do not have a direct impact on keeping the foot down, for example in toe walking, nor do they have any impact on the knee. The two kinds are called supramalleolar (SMO) or submalleolar, also called UCBL (University of California at Berkeley Laboratory). Braces are generally named for the joints they cross; the malleolus is the name of the ankle bone on the inside and outside. Therefore, a supramalleolar brace or SMO goes just above the ankle, so it keeps the foot from rolling in or out but allows any movement that the child is able to do at the ankle up or down, (dorsiflexion or plantarflexion). The submalleolar then is below the ankle bone and helps keep good foot position in those who have a slight tendency to roll inward on the ankle.

The next group of braces (AFOs) is used for leg control at the ankle for dorsiflexion (bending up) or plantarflexion (bending down) of the foot with no moving parts.  These give excellent positioning of the foot and ankle and do not allow toe walking. They also minimize the tendency for back kneeing, also called hyperextension of the knee or genu recurvatum. The leaf-spring AFO allows minimal plantarflexion and has no joint. The back of the brace is cut out. Both of these braces allow someone to walk and clear the floor without dragging their foot or toes. It keeps excellent positioning of the feet and ankles.

The third group of leg braces limits plantarflexion of the ankle but has a joint (articulation) that allows dorsiflexion of the foot. These allow a more natural flow in walking for those whose tone is not so severe that it does not overpower the brace. These have a joint at the ankle, which allows movement into dorsiflexion while limiting the plantarflexion and keeping good positioning of the feet. These are used for children with toe walking as well as knee hyperextension. These do not work for children who have a crouched gait pattern [walking with flexion (excessive bending) at the hips and knees].

For those children with a crouched gait, the fourth group of leg braces provides excellent positioning. These are called ground-reaction orthoses or floor-reaction orthoses (GRAFOs). These allow good control of the positioning at the ankle as well as good positioning at the knee and helps push the body into a more extended or straightened-up position. This is good for those with crouched gait or with weakness of the quadriceps, the muscle at the front of the thigh that straightens up the knee. There must be good range of motion at the knee to allow this to be effective; it will just cause a loss of balance if there is flexion contracture at the knee, and there must be some ankle strength. Additionally, this will not be effective in those who have crouching due to hypertonicity or increased muscle tone.

There have been some who advocate using inhibitive or tone-reducing footplates on braces of the feet. There is a limited amount of literature evaluating this, which basically shows some subjective improvements in function, gait and stride length. This has not been verified with more formal gait analysis. These types of braces appear to be popular for use in some regions of the country but not in others. It should be considered to help decrease tone, but again this is not scientifically validated. 

Traditional AFOs have been demonstrated to increase velocity, stride length and percent of time in single limb support in gait. AFOs improve gait by eliminating premature plantarflexion and improving progression of foot contact in stance. Using an articulated AFO shows an improved heel-toe gait pattern with improved ankle dorsiflexion at terminal stance and increased ankle power generation for pre-swing compared to solid AFOs. The articulated AFO has also been shown to reduce energy expenditure in gait. One study also showed that children with cerebral palsy were able to keep up with their peers better while wearing an articulated AFO.

Trunk Orthoses
Orthoses for the trunk are generally called TLSOs (thoracolumbosacral orthoses). The soft ones have previously been called corsets. They can be made of fabric or polypropylene material, which is the traditional material for leg braces as well. These are most commonly used in children with scoliosis. It does not fix the scoliosis nor does it change the endpoint of the curve that the back will have. It is used for helping with positioning to allow a good seating system. It is also used for skin protection. Treatment to fix scoliosis is surgical.

Wrist Hand Orthoses (WHO)
A variety of orthoses are used for the hands. These vary by age and with type of cerebral palsy. For infants with spasticity and particularly those who have their hand in a fist and their thumb inside the fist (cortical thumbing), very small neoprene straps, one going around the wrist and one going around the thumb, can be used to keep the hand open, provided the child is not too strong or the tone too overpowering. If that is the case, then a large neoprene wrist hand orthosis (WHO) is needed. These types of splint are excellent because they are soft and comfortable. They do not hurt and are not irritating. They can lead to excellent positioning of small hands and even larger hands that do not have significant tone or malpositioning. They can make positioning improvements as well as functional improvements in many children. These neoprene WHOs are optimal for school because they can help with improving function so that a child can hold pencils, crayons and utensils better and use the computer better. They also look fun and do not look medical. There are varieties of colors from which the child can choose.

Classically braces are made of a hard, strong plastic called polypropylene but other materials are also used. More traditional types of brace material such as polypropylene are frequently used for severe malpositioning at the wrist. For example, ulnar deviation in which the wrist is bent towards the side of the fifth finger, demands stronger positioning. If this is not too severe, it actually can be compensated for with a neoprene orthosis with a firm wrist insert. These are placed on the mid-wrist and are thin, flat pieces of metal, that fit inside the material away from the skin and can be molded to maintain positioning. They can also be molded to have a functional position of approximately 30 degrees of wrist extension if there is hypertonicity or malpositioning. Polypropylene or other firm wrist-hand orthoses are used if there are contractures, severe tone and for nighttime wear to have optimal positioning. Putting the hand in perfect functional position overnight with excellent stretch of the finger flexors and placement of the thumb in proper position may allow the hand to be more functional during the day when it does not have this large bracing on. In many cases, these braces are difficult to wear during the day due to interference with functional activities.

Communication Equipment
It has been reported that 88 percent of children with cerebral palsy have three or more disabilities, one of the most common being cognitive impairment or learning disabilities. Communication disorders are also common. There have been many advances in augmentative and alternative communication over the last 20 years. Some of the current improvements are those which have speech recognition systems for people with severe dysarthria so that they can access assistive technologies better.

The ability to communicate is critical for a child with cerebral palsy. Some children can communicate with no difficulty. Some will have good cognition and proper content of what they want to say but will have dysarthria (decreased clarity of the actual words or slurring of speech). Sometimes working with speech therapy and a home program can improve this to a very functional level. At other times, there is consideration of alternative means of communication. If there is a very significant oral motor incoordination, then alternative communication may be the answer. Some children communicate with the use of sign language. Some use picture boards or letter boards and point to what they want. Some use communication devices that are similar to that but are computer-based so that they can have a great deal more specificity. Some will type out on various word processing units, some of which have voice production to “speak” the words or sentences that the child types into the device. There are many options for communication devices from a simple yes/no switch to a complex word prediction device. Whatever the mechanism, it is critical that a child with cerebral palsy be able to communicate so that they can maximally interact with and control their environment.

Mobility Devices
Mobility in a child with cerebral palsy is also quite variable. A child may be sitting, then crawling or scooting and then walking in the months following that. If that is not the case, then developmentally it is important to attempt to mimic that upright positioning and mobility as much as possible. There are sitting devices to maintain an upright position. This is important for interactions that encourage communication and the use of both hands for manipulating objects. Some children will use a scooter board, which is very similar to a broad and padded skateboard to get around at home. There are wheelchairs appropriate for an 18-month-old child to propel himself. Even power wheelchairs can be manipulated by some children by 18 months of age if they have intact cognition and good hand-eye coordination. Some children cannot use hand controls but may be able to use a foot or head switch or other control device.

As children progress, many also work on walking, generally initially with braces and a walker, either anterior (front) or posterior (behind) rolling walker depending on their needs. For children who tend to lean forward in their gait, a posterior rolling walker (one they use behind them instead of in front) may be effective in helping them stand up tall. As coordination improves with age, they may be able to progress to the use of forearm crutches. This is to their functional advantage because they can get into smaller areas and go virtually anywhere with crutches, which is not the case for a walker due to its bulky size. Physical therapists (PTs) generally will help with all of these activities related to mobility.

ADL Equipment
Occupational therapists (OTs) generally help with self-care skills during child development. The therapists will also teach the family how to encourage the child in doing as much as possible of their own self care. They also will help with use of adaptive equipment at school or home. A reclining mesh bathtub chair is a commonly useful piece of equipment for increased comfort, safety and sometimes fun in bathing. Occupational and speech therapists may work together to address feeding difficulties. The speech therapist will work with language training, including any alternative devices.