Open Access Open Badges Study protocol

Optimising Ankle Foot Orthoses for children with Cerebral Palsy walking with excessive knee flexion to improve their mobility and participation; protocol of the AFO-CP study

Yvette L Kerkum12*, Jaap Harlaar12, Annemieke I Buizer1, Josien C van den Noort12, Jules G Becher12 and Merel-Anne Brehm12

Author affiliations

1 Department of Rehabilitation Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands

2 Research Institute MOVE, VU University Medical Center, Amsterdam, The Netherlands

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Citation and License

BMC Pediatrics 2013, 13:17  doi:10.1186/1471-2431-13-17

Published: 1 February 2013



Ankle-Foot-Orthoses with a ventral shell, also known as Floor Reaction Orthoses (FROs), are often used to reduce gait-related problems in children with spastic cerebral palsy (SCP), walking with excessive knee flexion. However, current evidence for the effectiveness (e.g. in terms of walking energy cost) of FROs is both limited and inconclusive. Much of this ambiguity may be due to a mismatch between the FRO ankle stiffness and the patient’s gait deviations.

The primary aim of this study is to evaluate the effect of FROs optimised for ankle stiffness on the walking energy cost in children with SCP, compared to walking with shoes alone. In addition, effects on various secondary outcome measures will be evaluated in order to identify possible working mechanisms and potential predictors of FRO treatment success.


A pre-post experimental study design will include 32 children with SCP, walking with excessive knee flexion in midstance, recruited from our university hospital and affiliated rehabilitation centres. All participants will receive a newly designed FRO, allowing ankle stiffness to be varied into three configurations by means of a hinge. Gait biomechanics will be assessed for each FRO configuration. The FRO that results in the greatest reduction in knee flexion during the single stance phase will be selected as the subject’s optimal FRO. Subsequently, the effects of wearing this optimal FRO will be evaluated after 12–20 weeks. The primary study parameter will be walking energy cost, with the most important secondary outcomes being intensity of participation, daily activity, walking speed and gait biomechanics.


The AFO-CP trial will be the first experimental study to evaluate the effect of individually optimised FROs on mobility and participation. The evaluation will include outcome measures at all levels of the International Classification of Functioning, Disability and Health, providing a unique set of data with which to assess relationships between outcome measures. This will give insights into working mechanisms of FROs and will help to identify predictors of treatment success, both of which will contribute to improving FRO treatment in SCP in term.

Trial registration

This study is registered in the Dutch Trial Register as NTR3418.

Cerebral Palsy; Pediatrics; Orthotic devices; Ankle foot orthoses; Intervention studies; Treatment effectiveness; Mobility; Participation; Gait