• Users Online: 270
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 99-112

Effect of walking aids and foot orthoses on energy expenditure in children with cerebral palsy: a systematic review

Physical Therapy for Pediatrics Department, Faculty of Physical Therapy, Cairo University, Giza, Egypt

Date of Submission18-Mar-2019
Date of Acceptance02-Jun-2019
Date of Web Publication9-Oct-2019

Correspondence Address:
PhD Walaa Abd El-Hakiem Abd El-Nabie
7 Ahmed Elzayat St Doky, Giza 12613
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bfpt.bfpt_3_19

Rights and Permissions

Background Walking aids and ankle–foot orthoses (AFOs) are designed to address gait problems. These devices are common among children with cerebral palsy (CP), as those children’s ability to ambulate is a big concern for their parents, and its improvement is considered primary focus of therapeutic modalities addressing motor disorders of this population. However, empirical support for walking aids and AFO is limited. The aim of this review was to assess the quality of research on the effect of walking aids and AFO on energy expenditure in children with CP.
Materials and methods Four electronic databases using predefined terms were searched by two independent reviewers. All study designs except case reports were included. Nineteen studies involving 509 participants met inclusion criteria and were involved in this review.
Results Heterogeneity was observed across included studies in measurement, implementation, and study rigor.
Conclusion There is a need for high-quality studies to draw a clear conclusion on the effect of walking aids and AFO on energy expenditure in children with CP; the typical flaws of existing studies included weak experimental designs, insubstantial treatment outcomes, and high risk of bias.

Keywords: cerebral palsy, energy expenditure, orthosis, systematic review, walking aids

How to cite this article:
Abd El-Nabie WE, Abd El Aziz HG, Elshennawy S. Effect of walking aids and foot orthoses on energy expenditure in children with cerebral palsy: a systematic review. Bull Fac Phys Ther 2019;24:99-112

How to cite this URL:
Abd El-Nabie WE, Abd El Aziz HG, Elshennawy S. Effect of walking aids and foot orthoses on energy expenditure in children with cerebral palsy: a systematic review. Bull Fac Phys Ther [serial online] 2019 [cited 2020 Sep 20];24:99-112. Available from: http://www.bfpt.eg.net/text.asp?2019/24/2/99/268684

  Introduction Top

Cerebral palsy (CP) is a familiar cause of postural and movement disorders among children, which are caused by damage of immature brain. Children with CP have pathological changes of musculoskeletal system. Disorders of balance, muscle tone, and strength are considered primary impairments that are related to central nervous system damage. However, joint deformities and muscle contractures occur in response to musculoskeletal growth and primary impairments and are termed as secondary impairments. All of these impairments allow children with CP to walk with inefficient pattern [1].

Ankle–foot orthoses (AFOs) have been recommended to enhance the dynamic gait efficiency of children with CP [2]. Many authors reported the effectiveness of different types of AFOs on gait kinematics and kinetics [2],[3], as well as functional performance, in children with CP [4].

Energy expenditure is the amount of oxygen consumed during physical exertion. The change in energy expenditure during activity reflects the metabolic cost of muscles, from moving the body against gravity and from accelerating and decelerating different body parts [5]. The appropriate use of walking aids improves efficiency, stability, and posture. Walking aids include canes, crutches, and walkers [6].

There is a strong relation between the degree of motor disorders and energy cost of walking [7]. Children with CP often begin their walking later than normal children [8] and walk with a higher energy cost and slower speed [9].

Independent mobility is important for participation, activity, and self-sufficiency, all of which decrease dependence on caregivers. Efficiency and safety are considered essential factors for selecting methods of mobility suited to different environmental conditions [10].

It is essential to measure energy consumption because of its role in the evaluation of functional ability as the quantification of energy expenditure; at the same time, walking provides objective data to assist in the evaluation of children with walking disabilities as well as effectiveness of therapeutic modalities, such as walking aids, orthoses, rehabilitation programmes, and surgical treatments [11].

A previous study performed on AFO and on different types of walkers concluded that high-quality studies are still required to support evidence-based decisions concerning the use of AFOs [12]; low quality of existing evidence and the heterogeneity prevent the recommendation of one walker type over the other, and well-designed studies are needed to provide clinical recommendations [13].

Therefore, there was a need for further research to provide adequate evidence to inform clinical recommendations, with adequately powered studies and careful design to minimize bias.

The purpose of this review was to assess the quality of present research on the effect of walking aids and AFOs on energy expenditure in children with CP.

  Materials and methods Top

Literature search

The authors underwent a training programme for online search to be able to perform the searching process in different databases. The following databases were searched to identify relevant published studies: the Cochrane Library, Scopus, PubMed, and the Web of Science. Those databases were searched by using the following keywords: energy expenditure, gait, walking aids, walkers, foot orthosis, CP, diplegia, and hemiplegia. Several search strategies were developed to accommodate the databases.

Study selection and eligibility criteria

Studies were included if they met the following criteria:


Children with different types of CP of both sex aged up to 18 years old were included. Methodology: studies that investigated the immediate or long-term effect of lower limb orthoses or any type of assisted walking aid on energy expenditure were involved. Study design: all research designs except case reports were accepted.


Full-text papers in English were included.

Data extraction

Two authors (Abd El-Hakiem Abd El-Nabie and Abd El-Aziz) extracted the following items from the included articles: (a) the author and year of publication; (b) information on the population, describing numbers of included children by diagnosis, age, and sex; (c) study design; (d) methodology, including the type of intervention or assessment, technique of its application, and its duration; (e) measured outcomes as explained by their authors; and (f) results. The extracted data are grouped into two tables: [Table 1] related to articles that evaluated the effect of orthosis on energy expenditure [14],[15],[16],[17],[18],[19],[20],[21],[22],[23], whereas articles investigating the effect of assisted walking aids, for example, a Walk Aide foot drop stimulator, walkers, sticks, a robotic-assisted gait trainer, and a flexible derotator, on energy expenditure [24],[25],[26],[27],[28],[29],[30],[31], were presented in [Table 2].
Table 1 Study design, sample details, methods and results for orthoses

Click here to view
Table 2 Study design, sample details, methods and results for assisted walking aids

Click here to view

Assessment of methodological quality

Methodological quality in the current systematic review was evaluated by the PEDro scale. This ten-item instrument is a valid measurement of methodological quality of clinical trials. The items are scored as present (1) or absent (0) [32]. Two reviewers (Abd El-Hakiem Abd El-Nabie and Abd El-Aziz) independently assessed the methodological quality of included studies, and discrepancies between them were resolved by consultation with the third author (Elshennawy) to reach the final decision. After each item was classified as ‘present’ or ‘absent’, the total score of each study was calculated as the sum of ‘present’ responses ([Table 3]). As reported by Foley et al. [33], the methodological quality was considered to be ‘excellent’ when studies scored from 9 to 10 on the PEDro scale, whereas studies scoring from 6 to 8 were considered ‘good’ quality, studies with 4 and 5 scores were graded as ‘fair’ quality, and studies with a score below 4 were classified as ‘poor’ quality.
Table 3 Level of evidence and methodological quality

Click here to view

Level of evidence

The level of evidence of all included studies was scored according to the modified Sackett scale ([Table 3] and [Table 4]). This five-level scale is used to determine the strength of evidence regarding the intervention ([Table 4]) [34].
Table 4 Modified Sackett scale

Click here to view

  Results Top

Literature search

The search strategy revealed 981 articles from previously mentioned databases, as follows: Cochrane Library (304), Scopus (70), PubMed (449), and Web of Science (158). Thirty-six duplicated articles out of 981 were found when the results from all databases were combined and screened for duplicate. The reviewers screened titles and abstracts of the remaining 945 articles independently, and the result of this screening was 53 included articles. Fifty-three articles were filtered on the basis of full-text; 34 were excluded because they were outside the scope, because the children’s diagnosis was not CP or outcome of interest was absent, or, in one case, the full-text paper was not available, as shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart ([Figure 1]). The remaining 19 studies formed the basis for the current systematic review.
Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart.

Click here to view

Characteristics of the studies

There was some variability among included studies regarding characteristics of participants (diagnosis and age), study design, methodology, outcome measures, and assessment methods.

Characteristics of participants

The children, who ranged from 3 to 18 years of age, were diagnosed with diplegic, hemiplegic, quadriplegic, and triplegic CP of different levels of severity. Both sexes were represented (261 boys and 173 girls). Two studies, namely, those of El-Shamy et al. [24] and Bhise et al. [14], did not identify sex distributions of their subjects.

Study designs

The included articles had a variety of study designs. There were 12 studies with cross-sectional design [4],[14],[17],[19],[20],[21],[22],[23], two pre–post experimental studies [15],[16], one RCT [24], one clinical trial [25], one case-series study [29], and two retrospective studies [2],[18], as shown in [Table 1] and [Table 2].


All studies in the current systematic review examined the effect of different types of lower limb orthoses (different configurations of AFO [4,14–16,18–23], plastic and metallic knee-AFO [17] or the effect of assisted walking aids (anterior and posterior walkers [27],[28],[30],[31], walking sticks [29], robotic-assisted gait training [25], flexible derotator [26] and Walk Aide foot drop stimulator [24]) on energy expenditure in children with CP. All included studies can be classified into the following types: (a) studies that investigated the immediate effect of lower limb orthoses [14],[17],[18],[20],[22],[23] or assisted walking aids [28],[30],[31] on energy expenditure, in which energy expenditure was assessed during the wearing of orthotic devices or during the usage of assisted walking aids and (b) studies that examined the long-term or cumulative effect of orthoses [4],[15],[16],[19],[21] or assisted walking aids [24],[25],[26] on energy expenditure, in which lower limb orthosis or assisted walking aids were applied for a specific duration (weeks or months). In these studies, energy expenditure was evaluated before and after treatment.

Types of outcome measured

Although energy expenditure was the outcome of interest in the present systematic review, there were other measured outcomes in the included studies, for example, kinematic and kinetic gait parameters [4, 16, 18–21, 23, 24, 26–28, 30, 31]; gross motor skills [4],[21],[22],[29]; metabolic and cardiopulmonary responses [22]; upper limb speed, dexterity, and kinematics [9],[28]; joint angles, power, daily walking activity, and range of motion [15],[21]; bone parameters [26]; joint reaction force and moments [27]; BMI and perceived exertion [14]; brace preference [20]; performance on the 6-min walking test [25]; and hand/forearm position [29].

Measurement of energy expenditure

Energy expenditure can be measured with different methods. In the present systematic review, all studies were accepted regardless of the method of measuring energy expenditure. Methods of measuring energy expenditure in the included studies were as follows: the energy expenditure index method [17],[18],[20],[26],[28] or the Physiological Cost Index method [4],[14],[23], in which energy expenditure was measured by subtracting the maximum heart rate from the resting heart rate and divided by speed of walking; an open-circuit indirect calorimeter [19],[24] or portable breath gas analysis system [15],[16],[18],[22],[30],[31] which assess energy expenditure by measuring the amount of oxygen consumption; the dilution model [4],[21]; and a SenseWear Armband ([Table 5]) [25]. [Table 5] shows methods of measuring energy expenditure in the included studies.
Table 5 Methods of measuring energy expenditure in the included studies

Click here to view

Level of methodological quality

The score of each study on the PEDro scale is presented in [Table 3]. The mean score of the 19 studies was 3.736. One study was given a score of 6 [24], one study obtained a score of 5 [23], nine studies had a score of four [15–17, 21, 26–28, 30, 31], and the remaining eight studies scored 3 [4],[14],[18],[19],[20]. One of the included studies represented ‘good’ quality [24], 10 studies were ‘fair’ quality [15–17, 21, 23, 26–28, 30, 31], and eight studies were ‘poor’ quality [4],[14],[18],[19],[20]. The criteria of a blinded therapist (criterion five) and intention-to-treat analysis (criterion eight) were not met by all included studies. On the contrary, the criteria of between-group statistical analysis (criterion nine) and estimation of point and variability measures (criterion 10) were satisfied by all included studies.

Level of evidence

According to the modified Sackett scale, one study [24] was ranked on level one, 13 studies were on level two [4],[14],[17],[19],[20],[21],[22],[23], two studies were on level three [18],[26], and three studies were on level four [15],[16],[29].

  Discussion Top

Our search in literature revealed moderate-quality to low-quality evidence on the effect of assisted walking aids and foot orthoses on energy expenditure in children with CP. The current systematic review aimed to collect this evidence by using systematic methods for search and evaluating best available studies on the benefit of assisted walking aids and foot orthoses for children with CP, based on clinically relevant outcomes including different methods of measuring energy expenditure, kinematic and kinetic gait parameters, and functional motor skills.

Energy expenditure among children with CP is very important as children with CP consume more energy during ambulation and they have lower physical activity levels and lower energy requirements than do typically developing children [35].

Figueiredo et al. [12] performed a descriptive review of literature about the effect of AFOs on gait in children with CP. They reported that studies with high-quality methods are still desired to support evidence-based decisions on the use of AFOs for those children. As, studies included flaws such as; lack of randomization procedures, lack of parity among groups and no masking of subjects, therapists, and examiners, except for one blinding was mentioned for examiners [12]. Consequently, there has been little progress in the quality of evidence since the last published review on orthoses. Instead of, we found that it is important to address other assisted walking aids used by children with CP to clarify its effect on energy expenditure because they were not addressed in any other systematic reviews. It should be borne in mind that ambulation with assisted walking aids is incorporated into daily life, so energy conservation is a major issue when choosing walking aids [30].

Different mechanisms have been suggested to clarify the advantage of foot orthoses for children with CP; one of them is the improvement of energy expenditure after using foot orthoses. Because the use of foot orthoses results in normal ankle motion during stance phase, this might lead to increased stability, with decreases in mechanical power and reduction in O2 cost of walking [36].

Another explanation mentioned when using other assisted walking aids like walkers revealed that posterior walker gives children with CP more stability as it decreases flexion angles of trunk, hips, and knees and gives more upright posture for them [37].

This review analyzed 19 studies; most of them were a cross-sectional design. This design enables researchers to estimate the prevalence of increased energy expenditure in children with CP and gave the best opportunities to know the different treatment modalities used to improve it. Studies with cross-sectional design provide a ‘snapshot’ of characteristics and outcomes associated with it, at a specific time [35]. Results of all included studies in this systematic review were consistent and agreed that foot orthoses and other assisted walking aids may improve energy expenditure in children with CP.

This review found moderate-quality to low-quality evidence supporting the use of foot orthoses and other assisted walking aids for children with CP; it also highlighted the variation in use of assisted walking aids and foot orthoses (types, duration, and technique of application), outcomes, and follow-up in the included studies. This clinical heterogeneity (characteristic of participants, absence of allocation concealment and blinding, small sample sizes, and wide variability) restricted the comparison between results of these studies and made meta-analysis inapplicable.

According to this results of PEDro scale, we had only two studies with moderate methodological quality and 17 studies with low quality. This might be owing to the absence of blindness in studies, which may be affected by the type of intervention used.

  Conclusion Top

Results of the current review revealed moderate-quality to low-quality evidence, and they were consistent and agreed that foot orthoses and assisted walking aids can improve energy expenditure in children with CP.


Well-designed and high-quality studies on the effect of foot orthoses and assisted walking aids on energy expenditure in children with CP are still needed to provide strong evidence.


The researchers wish to acknowledge our gratitude to the children, parents, and our volunteered colleagues.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Berker N, Yalcin S. The help guide to cerebral palsy. 2nd ed. Seattle, WA: Global Help; 2010. pp. 7–32.  Back to cited text no. 1
Radtka S, Skinner S, Johanson M. A comparison of gait with solid and hinged ankle-foot orthoses in children with spastic diplegic cerebral palsy. Gait Posture 2005; 21:303–310.  Back to cited text no. 2
Lam W, Leong JC, Li YH, Hu Y, Lu WW. Biomechanical and electromyographic evaluation of ankle foot orthosis and dynamic ankle foot orthosis in spastic cerebral palsy. Gait Posture 2005; 22:189–197.  Back to cited text no. 3
Buckon CE, Thomas SS, Jakobson-Huston S, Moor M, Sussman M, Aiona M. Comparison of three ankle foot orthosis configurations for children with spastic diplegia. Dev Med Child Neurol 2004; 46:590–598.  Back to cited text no. 4
Rose J, Ralston H, Gamble J. Energetics of walking. Chapter 3. In: Rose J, Gamble JG, editors. Human walking. 2nd ed. Baltimore: William and Wilkins; 1994. pp. 47–71.  Back to cited text no. 5
Axtel LA, Yasuda YL. Assistive devices and home modifications in geriatric rehabilitation. Clin Geriatr Med 1993; 9:803–821.  Back to cited text no. 6
Raja K, Joseph B, Benjamin S, Minocha V, Rana B. Physiological cost index in cerebral palsy: its role in evaluating the efficiency of ambulation. J Pediatr Orthop 2007; 27:130–136.  Back to cited text no. 7
Liao H, Jeng S, Lai J, Cheng C, Hsia-Hu M. The relation between standing balance and walking function in children with spastic diplegic cerebral palsy. Dev Med Child Neurol 1997; 39:106–112.  Back to cited text no. 8
Rose J, Medeiros J, Parker R. Energy cost index as an estimate of energy expenditure of cerebral-palsied children during assisted ambulation. Dev Med Child Neurol 1985; 27:485–489.  Back to cited text no. 9
Palisano R, Shimmell LJ, Stewart D, Lawless JJ, Rosenbaum PL, Russell DJ. Mobility experiences of adolescents with cerebral palsy. Phys Occup Ther Pediatr 2009; 29:135–155.  Back to cited text no. 10
Piccinin L, Cimolin V, Galli M, Berti M. Quantification of energy expenditure during gait in children affected by cerebral palsy. Eura Medicophys 2007; 43: 7–12.  Back to cited text no. 11
Figueiredo E, Ferreira G, Maia Moreira R, Kirkwood R, Fetters L. Efficacy of ankle-foot orthoses on gait of children with cerebral palsy: systematic review of literature. Pediatr Phys Ther 2008; 20:207–223.  Back to cited text no. 12
Poole M, Simkiss D, Rose A, Li F. Anterior or posterior walkers for children with cerebral palsy? A systematic review. Disabil Rehabil 2017; 13:1748–3107.  Back to cited text no. 13
Bhise S, Bane J, Parab S, Ghodey S. Comparison between physiological cost index in healthy normal children as against ambulatory spastic diplegic cerebral palsy (with and without orthosis) in the age group 6 to 18 years. Int J Physiother 2016; 3:395–400.  Back to cited text no. 14
Kerkum Y, Harlaar J, Buizer A, Noort J. An individual approach for optimizing ankle-foot orthoses to improve mobility in children with spastic cerebral palsy walking with excessive knee flexion. Gait Posture 2016; 46:104–111.  Back to cited text no. 15
Kerkum Y, Buizer A, van den Noort J, Becher J, Harlaar J, Brehm M. The effects of varying ankle foot orthosis stiffness on gait in children with spastic cerebral palsy who walk with excessive knee flexion. PLoS One 2015; 10:1–19.  Back to cited text no. 16
Uckun A, Celik C, Ucan H, Ordu G. Comparison of effects of lower extremity orthoses on energy expenditure in patients with cerebral palsy. Dev Neurorehabil 2014; 17:388–392.  Back to cited text no. 17
Brehm M, Harlaar J, Schwartz M. Effect of ankle-foot orthoses on walking efficiency and gait in children with cerebral palsy. J Rehabil Med 2008; 40:529–534.  Back to cited text no. 18
Balaban B, Yasar E, Dal U, Yazicioglu K, Mohur H, Kalyon TA. The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy. Disabil Rehabil 2007; 29:139–144.  Back to cited text no. 19
Smiley S, Jacobsen F, Mielke C, Johnston R, Park C, Ovaska G. A comparison of the effects of solid, articulated, and posterior leaf-spring ankle-foot orthoses and shoes alone on gait and energy expenditure in children with spastic diplegic cerebral palsy. Orthopedics 2002; 25:411–415.  Back to cited text no. 20
Buckon C, Thomas 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; 43:371–378.  Back to cited text no. 21
Maltais D, Bar-Or O, Galea V, Pierrynowski M. Use of orthoses lowers the O2 cost of walking in children with spastic cerebral palsy. Med Sci Sports Exerc 2001; 33:320–325.  Back to cited text no. 22
Mossberg K, Linton K, Friske K. Ankle-foot orthoses: effect on energy expenditure of gait in spastic diplegic children. Arch Phys Med Rehabil 1990; 71:490–494.  Back to cited text no. 23
El-Shamy S, Abdelaal A. WalkAide efficacy on gait and energy expenditure in children with hemiplegic cerebral palsy: a randomized controlled trial. Am J Phys Med Rehabil 2016; 95:629–638.  Back to cited text no. 24
Peri E, Biffi E, Maghini C, Marzorati M. An ecological evaluation of the metabolic benefits due to robotassisted gait training. Conf Proc IEEE Eng Med Biol Soc 2015; 2015:3590–3593.  Back to cited text no. 25
Marcucci A, Edouard P, Loustalet E, d’Anjou MC, Gautheron V, Degache F. Efficiency of flexible derotator in walking cerebral palsy children. Annals of Physical and Rehabilitation Medicine 2011; 54:337–347.  Back to cited text no. 26
Konop K, Strifling K, Wang M, Cao K. Upper extremity kinetics and energy expenditure during walker-assisted gait in children with cerebral palsy. Acta Orthop Traumatol Turc 2009; 43:156–164.  Back to cited text no. 27
Strifling K, Lu N, Wang M, Cao K, Ackman JD, Klein JP et al. Comparison of upper extremity kinematics in children with spastic diplegic cerebral palsy using anterior and posterior walkers. Gait Post 2008; 28:412–419.  Back to cited text no. 28
Toms B, Harrison B, Bower E. A pilot study to compare the use of prototypes of multipositional paediatric walking sticks and tripods with conventional sticks and tripods by children with cerebral palsy. Child Care Health Dev 2006; 33:96–105.  Back to cited text no. 29
Park E, Park C, Kim J. Comparison of anterior and posterior walkers with respect to gait parameters and energy expenditure of children with spastic diplegic cerebral palsy. Yonsei Med J 2001; 42:180–184.  Back to cited text no. 30
Mattsson E, Andersson C. Oxygen cost, walking speed, and perceived exertion in children with cerebral palsy when walking with anterior and posterior walkers. Dev Med Child Neurol 1997; 39:671–676.  Back to cited text no. 31
De Morton N. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 2009; 55:129–133.  Back to cited text no. 32
Foley N, Teasell R, Bhogal S, Speechley M. Stroke rehabilitation evidence-based review: methodology. Top Stroke Rehabil 2003; 10:1–7.  Back to cited text no. 33
Straus S, Richardson W, Glasziou P, Haynes R. Evidence-based medicine: how to practice and teach EBM. 3. Toronto: Elsevier Churchill Livingstone; 2005.  Back to cited text no. 34
Levin K. Study design III: cross-sectional studies. Evid Based Dent 2006; 7:24–25.  Back to cited text no. 35
Grossman J, Mackenzie F. The randomized controlled trial: gold standard, or merely standard? Perspect Biol Med 2005; 48:516–534.  Back to cited text no. 36
Logan L, Byers-Hinkley K, Ciccone C. Anterior versus posterior walkers: a gait analysis study. Dev Med Chid Neurol 1990; 32:1044–1048.  Back to cited text no. 37


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded158    
    Comments [Add]    

Recommend this journal