FOOT PRESSURES WITH AND WITHOUT BRACING IN PATIENTS WITH CEREBRAL PALSY (CP). Anil Bhave; Roland Starr; Scott Tennis*; Cindy Schreiber; John Herzenberg RIAO, Sinai Hospital, Baltimore, MD PURPOSE: To determine if bracing improves the distribution of foot pressure in patients with CP. BACKGROUNDS/SIGNIFICANCE: Foot pressure in subjects without gait deviations is distributed from the heel along the lateral border of the foot to the metatarsal heads. In patients with CP foot pressure is typically increased in the forefoot with mid foot breakdown and decreased pressure to the hind foot. Bracing is thought to improve the distribution of weight through the foot in walking in patients with Cerebral Palsy. There is limited data as to the foot pressure characteristics of patients with CP with and without bracing. SUBJECTS: 23 subjects diagnosed with Cerebral palsy with 41 involved lower extremities with an age range of 4 to 18 years (mean 10.39 years). There were 13 males and 10 females. Diagnoses ranged from spastic diplegia (10), quadriplegia (1), asymmetric diplegia (4), left hemiplegia (3), right hemiplegia (1), and triplegia (4). METHODS AND MATERIALS: The study design was a retrospective chart review of all pediatric subjects tested from 6/03 through 7/04 with a diagnosis of Cerebral Palsy who underwent foot pressure studies with and without braces. All subjects were tested during walking using the Tekscan Pressure Measurement System version 4.12F (TEKSCAN, S. Boston, MA). All subjects wore one of 3 braces: an AFO, a hinged AFO or a dynamic AFO. All braces were properly fitting and were properly worn at the time of testing. Tekscan sensors were placed between the foot and the shoe for the shoe condition and between the brace and the foot for the brace condition. Foot pressure data was analyzed using a scoring method devised by authors that devided the foot into six quadrants. A midfoot breakdown with pressure on the medial midfoot was assigned a negative score, while adequate pressure (greater than 1/10 of the body weight) in the rest of the foot was given a positive score. In addition to analysis of foot pressure data we also obtained measurements from a detailed clinical exam that include ROM of hip, knee, ankle and pelvic tilt. Hamstrings and gastrocnemius length were measured dynamically (R1) and statically (R2) with R1 the measured angle where the spasticity initiates upon a fast stretch of the muscle and R2 is the maximum range of motion. ANALYSES: Comparisons were made between the measured variables using Statview v5.0.1 (SAS Institute Inc., Cary, NC). The variables considered included the foot pressure scores inside the shoes and foot pressure scores inside the braces. In addition to the foot scores, the other variables included: Gastrocnemius R1 and R2 physical exam measures; maximum soleus range of motion; minimum anterior pelvic tilt during the gait cycle; hamstring R1 and R2 physical exam measures. The bracing worn during the testing was considered as a factor and divided the data into three groups, AFOs, Hinged AFOs and DAFOs. The Hip fixed flexion deformity (HFFD) as also used as a factor by coding it as present if it was measured > or = 10 deg and absent if it was measured < 10 deg; The Knee fixed flexion deformity (KFFD) was also used as a factor by coding it as present if it was measured to be > or = to 10 degrees and absent if it was measured as < 10 degrees. A paired t-test was performed between the foot scores with and without braces. Paired t-tests were also performed between the shoe foot pressure score in patients when HFFD and KFFD were present with the shoe foot pressure score in patients when HFFD and KFFD were absent. Paired t-tests were performed between the shoe foot pressure score in patients when HFFD and KFFD present with the brace foot pressure score in patients when HFFD and KFFD present. A paired t-test was performed between the patients with a HFFD and no KFFD in shoes and patients with a HFFD and no KFFD in braces. A paired t-test was performed between the patients with no HFFD and a KFFD in shoes and patients with no HFFD and a KFFD in braces. A paired t-test was performed between the patients with no HFFD and no KFFD in shoes and patients with no HFFD and no KFFD in braces. Linear regression plots were also calculated with the braced foot pressure scores vs gastrocnemius R1, maximum gastrocnemius length and soleus length. Linear regression analysis was also used to determine correlation between the braced foot pressure score and hamstring R1 values. RESULTS: The paired t-test between the foot scores with shoes and the foot scores with braces showed a statistically significant difference between the groups (p < 0.0001) with the shoe foot scores higher than the foot scores in the braces. All the remaining paired t-tests showed that there was a statistically significant difference between the conditions at the p=0.01 level except for the paired t-test between the foot pressure score for patients with no HFFD or KFFD in shoes and patients with no HFFD or KFFD in braces( p = 0.07) All regressions showed no correlation between the braced foot pressure scores and the gastrocnemius and soleus variables. CONCLUSIONS: Our study indicates that customized bracing of the ankle and foot in ambulatory patients with CP does not result in improvement in foot pressure scores as compared to in shoe foot pressure. On further analysis of factors that cause this it appears that presence of hip and knee contractures led to poorer foot pressures in our study as compared to in-shoe foot pressures. Most patients showed inferior results with braces due to mid-foot breakdown with pressure on the medial portion of the mid- foot. Careful analysis and resolution of hip and knee flexion contractures should be considered before prescribing ankle-foot-orthosis in ambulatory patients with cerebral palsy. FUNDING SOURCE: none KEYWORDS: Cerebral Palsy, Gait, Foot pressure, Bracing, AFO Copyright 2009 by the American Physical Therapy Association. Requests for reprints should be directed to the corresponding author of the article. Educators, students, and other academic customers may receive permission to reprint copyrighted material from Physical Therapy (ISSN 1538-6724) by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. 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