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Commentary on “Effect of Knee Orthoses on Hamstring Contracture in Children With Cerebral Palsy: Multiple Single-Subject Study”

Le Cras, Sally PT, DPT, PCS; Greve, Kelly PT, DPT, PCS

Pediatric Physical Therapy: October 2016 - Volume 28 - Issue 3 - p 354
doi: 10.1097/PEP.0000000000000287

Cincinnati Children's Hospital Medical Center, Mount St. Joseph University Cincinnati, Ohio

Cincinnati Children's Hospital Medical Center Cincinnati, Ohio

The authors declare no conflicts of interest.

“How should I apply this information?”

Long sitting with knee orthoses is commonly recommended to maintain or increase hamstring muscle length in children with cerebral palsy (CP), yet evidence has been limited in demonstrating its effectiveness or providing dosing parameters. Interventions focused on Body Structure and Function within the International Classification of Functioning, Disability, and Health Framework may not result in direct improvements in Activity or Participation. Therefore, clinicians should use appropriate Activity or Participation outcome measures as an adjunct to range of motion (ROM) and spasticity measures to document functional and quality-of-life changes after intervention. Long sitting with knee orthoses (KOs) 30 minutes per day, 5 days per week, can be performed with patients/students in a variety of settings with supervision and monitoring by a pediatric physical therapist. Compliance and results, however, may vary in settings with less support from paraprofessionals, aides, or parents.

“What should I be mindful about when applying this information?”

Group results of this study should be considered cautiously due to the atypical analysis of the single subject research design and diminished power to show change in a diverse group of 10 children with CP. Although ROM gains reached clinical significance on the basis of the Swedish National Surveillance program, these ROM ranges have not been validated or correlated with functional outcomes. Pelvic position in long sitting was not noted, raising concern of overstretching the lumbar and hip extensors in a posterior pelvic tilt position. Long sitting was performed in slight hip abduction, but further research of hip joint stability with hamstring stretching is needed.1 Custom KOs can be costly and need to be modified or remade frequently because of growth. More cost-effective methods should be considered in future studies, such as off-the-shelf KOs. It is unclear whether the attached ankle foot orthotics affected the results. The authors should be commended for adding to the evidence for improving hamstring flexibility in this heterogeneous population of children with CP.

Sally Le Cras, PT, DPT, PCS

Cincinnati Children's Hospital Medical Center, Mount St. Joseph University

Cincinnati, Ohio

Kelly Greve, PT, DPT, PCS

Cincinnati Children's Hospital Medical Center

Cincinnati, Ohio

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1. Chang CH, Chen YY, Wang CJ, Lee ZL, Kao H-K, Kuo KN. Dynamic displacement of the femoral head by hamstring stretching in children with cerebral palsy. J Pediatr Orthop. 2010;30(5):475–478.
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