Are AFO research studies for children with cerebral palsy falling short on clinical reporting?

A new scoping review has raised important concerns about how ankle foot orthosis (AFO) interventions are reported in clinical research involving children with cerebral palsy (CP). Despite the existence of international guidelines published in 2010, many studies still lack the basic details needed to understand and replicate how AFOs are used and aligned.

Our orthotist Catherine Hendy co-authored the review alongside world reknown physiotherapist Elaine Owen MBE. Sixty-four full-text studies published between 2010 and mid-2024 were analysed. All the studies involved rigid AFOs for children with cerebral palsy. The aim was to assess how well these studies adhered to best-practice reporting guidelines.

What Should AFO Studies Report and Why Does It Matter?

The 2010 best practice guidelines, listed in the EQUATOR Network, outline three parameters that should be included in any AFO research:

• Ankle Angle of the AFO (AA AFO): The angle of the foot relative to shank/tibia in the sagittal plane, described in degrees of dorsiflexion or plantarflexion, 0° or 90° describing neutral alignment.
• Shank to vertical angle of the AFO footwear combination (SVA AFOFC): The angle of shank relative to the vertical when standing in AFOFC with weight equally distributed between heel and sole, measured in sagittal plane. Described as vertical, or in degrees of incline if leaning forward, or recline if leaning backward. SVA-AFOFC is a ‘static alignment’ measure.
• Tuning or optimisation: Tuning is the process whereby adjustments are made to the design of the AFOFC during trials of an activity, in order to optimize its performance. In particular SVA-AFOFC alignment, and heel and sole designs of the footwear. Tuning is done by observing segment and joint kinematics, and if available kinetics, during the activity for which the AFOFC is being tuned, e.g., walking.

These three parameter are not just technical details; they are crucial to ensuring an AFO intervention is effective, safe, and appropriate. Without them, it is hard to interpret, replicate, or apply a study’s outcomes in clinical practice.

What did the review find about AFO reporting in cerebral palsy research?

From an initial pool of 558 records, only 64 met the inclusion criteria: full-text English-language studies of rigid AFOs used with children with cerebral palsy.

Here’s how those 64 studies measured up:

• only nine studies (14%) reported all three parameters: AA AFO, SVA AFOFC and tuning
• two studies (3%) reported two out of three
• twenty-one studies (33%) reported only one
• thirty-five studies (50%) did not report any of the three outlined three parameters

This means that in half of the studies reviewed, none of the key alignment or tuning factors were documented, even though they are considered essential by international consensus.

The authors also noted that reporting was inconsistent, even among studies that included some parameters. Definitions varied, tuning procedures were often unclear, and few studies explained how alignment decisions were made.

How does poor AFO reporting affect children and their families?

Rigid AFOs are often prescribed to improve walking, posture and standing in children with cerebral palsy, but their effectiveness depends on how well they are aligned and tuned for each individual child. These details make a significant difference to outcomes.

When research leaves these out:

• clinicians lack evidence they can trust or apply in practice
• families may not understand what to expect from treatment
• future studies cannot compare or build on earlier findings

Ultimately, poor reporting means missed opportunities to improve care for children who rely on these interventions.

What needs to change in AFO research reporting?

The authors recommend:

• consistent use of the 2010 best practice reporting guidelines
• clear documentation of AA AFO, SVA AFOFC, and any tuning carried out
• reviewers and editors to flag poor reporting as a limitation
• clinical teams to routinely record these parameters in their own practice

Improving how AFO interventions are reported in research will not just benefit academic study; it will help real children get better outcomes from the devices they use every day.

Our view

As a clinical team committed to evidence-based, personalised care, we believe orthotic research must reflect what matters in practice. That includes capturing how AFOs are aligned, tuned and tailored, not just which designs we use.

Read the full paper via the Journal of Prosthetic and Orthotics: Do authors and editors comply with best practice reporting guidelines for AFO interventions in studies involving children with cerebral palsy? A scoping review.

If you have questions about AFO alignment, tuning or support for your child’s walking. We’re here to help. Get in touch with our clinical team.