variations in the orthotic management of cerebral palsy

© 2002 Blackwell Science Ltd 139

Variations in the orthotic management ofcerebral palsy

Christopher Morris,* Helen Newdick† and Ann Johnson†

*Department of Orthotics, Nuffield Orthopaedic Centre NHS Trust, Oxford, and †Oxford Register of EarlyChildhood Impairment, National Perinatal Epidemiological Unit, Institute of Health Sciences, University ofOxford, Oxford, UK

Accepted for publication 30 November 2001

AbstractO b j e ct i ve Anecdotal reports that children with cerebral palsy were provided different orthoses in

two adjacent UK health districts were investigated using an observational comparative case study.

M e t h od The populations were compared using an epidemiological register of children with

cerebral palsy, which confirmed that a comparable health service response could be expected.

Merging data from the register with the orthotic patient database facilitated comparison of the

orthoses prescribed in each district. A survey questionnaire was used to gather the perceptions of

clinicians in both districts to understand how each team decides which orthosis to prescribe.

R e s u l t s There was considerable variation in the types of orthoses prescribed between districts, and

particularly of ankle foot orthoses. Survey respondents from the same profession described having

the same roles, although clinicians expressed different responsibilities for initiating and sanctioning

orthotic prescriptions in their district programmes.The survey also suggested that most clinicians

were uncertain when prescribing orthoses, and clinical practice was therefore largely determined by

professional preference.

C o n c l u s i o n Defining the spectrum of activity limitation in geographically defined populations

would enhance health services research and assist in the development of trials using different

interventions to reduce those limitations.

Correspondence:Department of Orthotics,Nuffield Orthopaedic CentreNHS Trust, Oxford OX3 7LD,UKE-mail:[email protected]

Original Article

Keywordscerebral palsy, orthoses,multidisciplinary,epidemiology

Background

The evaluation of health services for children with

cerebral palsy is a neglected area of research.

Despite this, a variety of medical, surgical and

therapeutic interventions is used in an attempt to

reduce the musculoskeletal deformities and activity

limitations that result from the effect of growth on

the neurologically impaired child. These include

orthopaedic and neurosurgical procedures and

drugs that may be administered orally, intramuscu-

larly or intrathecally. Alongside these medically

delivered interventions, children frequently receive

occupational therapy and physiotherapy, tempo-

rary casting or splinting and orthoses. Orthoses

are externally applied devices used to modify struc-

tural and functional characteristics of the neuro-

muscular and skeletal systems by exerting forces

on the body (International Organization for

Standardization 1989; Bowker et al. 1993). Contem-

porary orthoses are usually custom-fabricated from

thermoplastics that are moulded over rectified plas-

ter models of the affected part of the body. The

organization of services providing orthoses in the

UK National Health Service (NHS) was shown to

be highly variable between districts (Audit

140 C. Morris e t a l.

© 2002 Blackwell Science Ltd, C h i l d : C a re , H e a l t h & De v e l o p m e n t, 28, 2, 139–147

Commission 2000). Similarly, healthcare pro-

grammes for childhood disability in the UK are

organized at a local district level and are also deliv-

ered in a variety of ways (McConachie et al. 1999).

Organizing the delivery of multidisciplinary health

services is of course a complex challenge. However,

previous descriptions of child disability services, by

Robards (1994) for example, have not incorporated

many of the specialist services that are often essen-

tial for children with cerebral palsy, such as

orthopaedics, orthotics, assistive technology and

wheelchairs.

The assessment of a specific child’s needs and the

setting of treatment goals may result in a referral for

an orthosis as part of a physical management plan.

The treatment goals, which may target structural

(impairment) problems or overcoming activity

limitations, must be transformed into realistic bio-

mechanical objectives to allow a specific design of

orthosis to be made. Members of the team then

need to encourage acceptance of the orthosis and

evaluate whether the contribution of the orthosis to

the overall plan has enabled the treatment goals to

be achieved. Further details of the orthotic supply

process are described by Condie & Stewart 1997).

Evidence-based practice in the selection of

orthotic designs for children with cerebral palsy is

undermined by studies that have been poorly

designed and have included small numbers of

children with short follow-up periods (Condie &

Meadows 1995; Morris 2001). The difficulties in

mounting randomized controlled trials in this

population are well recognized (Davidson 1999;

McConachie 1999). As cerebral palsy is a heteroge-

neous condition with a wide range of neurological

impairment, assembling groups of children with

comparable baseline characteristics for recruitment

into a trial can be perceived as an obstacle. There is

also the difficulty of ascertaining clear and simply

measured outcomes. Perhaps the most difficult

problems to overcome are the strongly held views of

clinicians and families on the relative values of dif-

ferent treatment approaches that prevail in the

absence of good evidence.

The opportunity for the research study reported

here arose from discussions among orthotists

working at the Nuffield Orthopaedic Centre NHS

Trust (NOC) in Oxford during the 1990s. The NOC

had provided the primary clinical and technical

orthotic service in the two adjacent health districts

of Oxfordshire and West Berkshire. Anecdotally,

orthotists had described being asked to provide

quite different orthoses to apparently similar chil-

dren with spastic equinus of the foot and ankle

depending on whether they were in Oxfordshire or

West Berkshire. In this study, we addressed the fol-

lowing questions:

1 Do the populations of children with cerebral

palsy in each district present similar needs for

health services?

2 To what extent does orthotic prescription vary

for children with cerebral palsy between different

districts?

3 How do the multidisciplinary teams in each

district make decisions about which orthosis to

prescribe?

Methods

An observational comparative case study of the

health services provided in two geographically

defined adjacent districts was conducted, gathering

mixed quantitative and qualitative methods within

an established programme evaluation framework

(Centers for Disease Control & Prevention 1999).

Characteristics of populations

The Oxford Register of Early Childhood

Impairment (ORECI) was used to compare the

populations with cerebral palsy in each district.

Since 1984, ORECI has monitored the prevalence

of children with cerebral palsy born to mothers

resident in the four counties of Buckinghamshire,

Northamptonshire, Berkshire and Oxfordshire. In

addition, the register includes information on chil-

dren with cerebral palsy who move into the area.

When cases of cerebral palsy are confirmed on the

register, usually at age 5 years, the paediatrician

completes a questionnaire about the child that

records various aspects of their physical character-

istics.With the approval of the ORECI management

committee, anonymous data were extracted on 452

children with a confirmed diagnosis of cerebral

palsy aged between 5 and 16 years. After excluding

Variations in the orthotic management of cerebral palsy 141


children who had died (42 children) or were now

residing outside the two districts of interest (42

children), 370 remained (Oxfordshire 193 and West

Berkshire 177). These data were used to compare

the baseline characteristics of the populations in

each district and to judge whether they present

similar needs for physical management.

Orthotic prescription

The NOC orthotic patient database was used to

review retrospectively the orthoses prescribed to

the children with cerebral palsy identified by

ORECI. At the time of the study, the orthotic

patient database at the NOC contained more than

4200 children who had been provided with

orthoses, born in or after 1984, from more than 20

districts and who have various but unrecorded

diagnoses. The orthotic database provided infor-

mation about both the type of orthosis and the

medical prescriber for a 9-month period between 1

August 1999 and 30 April 2000. The time interval

was limited by the new orthotic information tech-

nology (IT) system and would not necessarily cap-

ture all the children on the register using orthoses. It

takes an average of 10 months and up to 18 months

for a child to outgrow their ankle foot orthosis

(AFO) (Supan & Hovorka 1995).

Children with a confirmed diagnosis of cerebral

palsy who had been provided orthoses were identi-

fied by bringing the databases into a common for-

mat and using the date of birth and gender of each

child to retrieve a child’s name from the orthotic

database. The ORECI database manager then

checked the information and confirmed that 198 of

these names were matched with the correct unique

identifier on the register. A report of the types of

orthoses that had been provided for the children

during the 9 months was then produced. The pro-

portions of children with cerebral palsy in each dis-

trict that were prescribed specific orthoses were

compared.

Clinician survey

A sample of service providers in the programme

was invited to participate in a cross-sectional sur-

vey. This was designed to collect quantitative infor-

mation about indicators of the structure, processes

and outcomes of each district programme in-

cluding how the decision was made to prescribe

orthoses in each district.

Sample selection criteria

Orthoses are provided within multidisciplinary

physical management programmes that span hos-

pital and community health services. The survey

invited all the healthcare professionals regularly

involved in the process of orthotic prescription

identified by the lead author as a participant

observer. A subsample of general practitioners was

invited to participate, represented by the Chairs of

the then Primary Care Groups. The questionnaire

was distributed to the target population by post or

through members of the steering committee who

acted as gatekeepers to the larger professional

groups (physiotherapists, paediatricians and

orthotists).

Questionnaire development

The survey document was developed with open

and closed questions in four sections: professional

background, interprofessional communication,

multidisciplinary working and clinical practices

relevant to orthotic management (a copy of the

questionnaire can be obtained from the lead

author). In the ‘professional background’ section,

respondents indicated their profession, the district

in which they worked and the locations where they

saw children with cerebral palsy. These were used

as indicators of the structure of the programme.

Clinicians recorded their familiarity with the bio-

mechanical (musculoskeletal), neurodevelopmen-

tal and conductive education paradigms, identified

by Bower (1999), and also described their own

professional role. In the ‘interprofessional commu-

nication’ and ‘multidisciplinary working’ sections,

the survey gathered the service providers’ percep-

tions of indicators of programme efficiency and the

equity of services as part of a larger study (Morris

2000). In the ‘clinical practice’ section, participants

were asked categorically whether they were aware of

variations in orthotic management and, in open

questions, how they decide which orthosis to pre-



scribe and how they involved the parents in the

decision. Open questions were designed to remove

the constraints of predetermined categories of

answers and to encourage respondents to express

their own perceptions of the programme. An

opportunity for respondents to add their own com-

ments was included at the end of the questionnaire.

This gathered many comments on the programmes

that were not elicited by responses to specific

questions.

Questionnaire analysis and validation

The text responses were systematically transcribed

in full, organized and coded using content analysis

and the identification of themes. The frequency

of responses to closed questions was coded and

analysed quantitatively using an SPSS database with

the profession and district in which the respondents

worked as the independent variables. The findings

were then presented to the same survey sample for

respondent validation. The validation process

offered all participants the opportunity to com-

ment on a report of the survey and observational

findings, in particular to ensure that individual

quotes had not been used out of context.

Results

Comparing district populations

The characteristics of the populations of cerebral

palsy were compared between Oxfordshire and

West Berkshire, and the findings are shown in

Table 1.

There are more boys than girls affected in both

districts (difference = 0.06, 95% CI –0.49 to 0.15).

Children classified with spastic cerebral palsy

account for the largest group in each district (89%

in Oxfordshire and 80% in West Berkshire). The

differences in diagnosis between the districts was

significant (c2 = 9.6295, d.f. = 3, p < 0.05). This

appears to result from the higher proportions of

spastic impairments reported in Oxfordshire and

the higher proportion with dyskinetic diagnoses in

West Berkshire. More children with ‘spastic’ cere-

bral palsy were described with impairments affect-

Table 1. Comparison of the populations of children with cerebral palsy in Oxfordshire and West Berkshire

WestBerkshire Oxfordshire Total

n (%) n (%) n (%) Diff. 95% CI z P

Female 77 (44) 74 (38) 151 (41)Male 100 (56) 119 (62) 219 (59) 0.06 -0.49 to 0.15 1.01 >0.2Diagnosis (SCPE classification)

Spastic 141 (80) 171 (89) 312 (84)Dyskinetic 21 (12) 8 (4) 29 (8) c2 = 9.6295 d.f. = 3 <0.05Ataxia 10 (6) 6 (3) 16 (4)Unclassifiable 5 (3) 8 (4) 13 (4)

Extent of spastic motor impairmentBilateral 79 (45) 102 (53) 181 (49)Hemiplegia 62 (35) 69 (36) 131 (35) c2 = 0.4165 d.f. = 1 >0.2Not spastic 36 (20) 22 (11) 58 (16)

Walking ability (one case of missing data)Not walking 41 (23) 59 (31) 100 (27)Restricting lifestyle 32 (18) 36 (19) 68 (18) c2 = 0.302, d.f. = 3 >0.2Functional/non-fluent 87 (49) 75 (39) 162 (44)Walks fluently 17 (10) 22 (11) 39 (11)

Contractures (seven cases of missing data)Total with contractures 48 (27) 78 (40) 126 (34) 0.13 0.04 to 0.24 2.70 <0.01Spastic 43 (24) 74 (38) 117 (32)Dyskinetic 5 (3) 3 (2) 8 (2)Ataxia - - - - - -Unclassifiable - - 1 - 1 (0.3)

Total 177 193 370



ing both sides of their body in Oxfordshire (53%)

than in West Berkshire (45%). However, excluding

those children classified with the non-spastic

subtype, the difference between the proportions

of bilaterally and unilaterally (hemiplegic) spastic

cases in each district was not significant

(c2 = 0.4165, d.f. = 1, p > 0.2). There were similar

proportions in each of the walking ability categories

in each district (c2 = 3.418, d.f. = 3, p > 0.2).

Although there were more children classified

as ‘functional but not fluent’ walkers in West

Berkshire, the differences between the other strata

were not statistically significant. The frequency that

children were reported as having joint contrac-

tures in each district subdivided by SCPE diagnostic

classification (Surveillance of Cerebral Palsy in

Europe 2000) is also shown in Table 1. However, it

should be noted that, although hip, knee and ankle

were more commonly reported in supporting text,

upper and lower limb contractures could not be

satisfactorily separated in the data, and both were

included in the analysis. Contractures were more

likely in children with spastic or dyskinetic cerebral

palsy than for those with ataxic or unclassifiable

impairments. Children were more frequently

reported as having contractures at age 5 years in

Oxfordshire (78/193, 40%) than in West Berkshire

(48/177, 27%): the difference was 13% (95% CI

0.04 to 0.23).

There was evidence of a correlation between

walking ability at 5 years of age and the presence of

contractures reported to ORECI (Table 2). The

findings show that children who were not walking

were twice as likely to have been reported to have

joint contractures when compared with those with

any walking ability: relative risk (RR) = 2.51 (95%

CI 1.93 to 3.26). The increased risk of contractures

for children who were not walking was a consistent

finding relative to all the walking ability categories.

These relative risks were ‘not walking’ vs.‘restricting

lifestyle’: RR = 1.44 (95% CI 1.05 to 1.98); ‘not walk-

ing’ vs. ‘functional/non-fluent’: RR = 2.78 (95% CI

2.00 to 3.85); and ‘not walking’ vs. ‘walks fluently’:

RR = 1.99 (95% CI 1.50 to 2.52).

Comparing orthotic prescription

Half the children recorded with ORECI in both

districts were prescribed orthoses in the sample

9-month period (Oxfordshire 49% and West

Berkshire 48%). There were 89 children in

Oxfordshire who had received 123 orthotic prescri-

ptions and 80 children in West Berkshire who had

received 114 prescriptions. Children in Oxfordshire

were principally referred for orthotic management

by a single orthopaedic surgeon (85 referrals, 96%)

and in West Berkshire primarily by one paediatri-

cian (46 referrals, 57%) or a single orthopaedic sur-

geon (34 referrals, 43%). There was a wide range of

orthoses prescribed for all parts of the body detect-

ed by the merging process. However, the anecdotal

reports related to lower limb orthoses, and it is these

that are shown in Fig. 1.

The variation between districts was most notable

in the prescription of rigid designs of AFOs:

Oxfordshire 54/89 children or 61% (95% CI 51 to

71%); West Berkshire only 17/80 children or 21%

(95% CI 12 to 30%). The difference in the propor-

tions of children prescribed rigid AFOs in each dis-

trict was significant: 40% (95% CI 27 to 53%).

There was also a difference in the greater propor-

tion of children prescribed footwear in West

Berkshire (42/80, 53%) compared with Oxfordshire

(25/89 or 29%): difference = 24% (95% CI 10 to

39%). Only one child was prescribed a pair of

supramalleolar DAFOs in Oxfordshire, but 17 chil-

dren were prescribed these in West Berkshire.

Further statistical analyses of the differences in

Contractures

Yes % No % Total

Not walking 60 62.5 36 37.5 96Restricting lifestyle 29 43.3 38 56.7 67Functional/non-fluent 36 22.5 124 77.5 160Walks fluently 1 2.7 37 97.3 38

Total 126 235 361

Table 2. Cases identified withcontractures in both districtsstratified by walking ability (ninecases of missing data)



orthotic prescriptions between districts was not

appropriate, as the numbers for some orthoses

were small, and some children received more than

one orthosis. It was discovered later that, in

Oxfordshire, a small proportion of children’s

orthopaedic footwear is purchased directly from

suppliers by physiotherapists and including these

might reduce the difference in prescribed footwear.

Oxfordshire children were also more frequently

prescribed heel cups, wrist orthoses and shoe raises.

West Berkshire children were more often prescribed

spinal orthoses, head supports and protective hel-

mets during the 9 months in which data were

gathered.

Clinician survey

In total, 49 clinicians responded from eight pro-

fessions who were equally representative of the

teams working in Oxfordshire and West Berkshire.

These included two paediatric neurologists, two

orthopaedic surgeons, 12 hospital or community

paediatricians, 23 hospital and community-based

physiotherapists, seven orthotists and four general

practitioners.

Programme structure

Responding clinicians from each district were

employed by at least three separately managed NHS

Trusts. Together, the different professions described

seeing children at several hospital sites and numer-

ous school locations.

Treatment paradigms

Although each discipline described similar profes-

sional roles in both districts, the survey indicated

that there were differences in the treatment para-

digms that guide their clinical practice. Almost all

the respondents were aware of each of the therapeu-

tic paradigms offered in the question. Most clini-

cians in Oxfordshire (22/27; > 80% of respondents)

and the majority in West Berkshire (13/21; > 60%)

were regularly using the biomechanical paradigm.

As the ‘neurodevelopmental’ and ‘conductive edu-

cation’ paradigms are primarily therapy orientated,

few clinicians indicated using these except physio-

therapists. Many physiotherapists are therefore

integrating different complex treatment paradigms

that attempt to blend the objectives of medical and

Figure 1. Bar chart showing frequency with which different lower limb orthoses were prescribed.



educational philosophies. One physiotherapist

described how:

‘All the therapies tend to have individual goals

and the paediatricians/orthopaedic surgeons

another set. Once the child is school age, the two

are more difficult to integrate, and education

have yet another set’.

Orthotic prescription

Most professionals indicated that they were aware

that there were variations in orthotic management

(14/17 in West Berkshire, 22/24 in Oxfordshire and

3/3 working in both districts). One community

physiotherapist commented that:

‘Different areas/localities seem to have different

ideas of the intended effect of DAFOs and differ-

ent ways of actually producing them – as I see

children from different areas in school, their

orthotics vary considerably’.

The themes that emerged from respondents

relating to how orthotic prescriptions are made in

each district were divided into ‘responsibility for

authorizing prescriptions’ and ‘factors affecting

orthotic prescription’.

Responsibility for prescribing orthoses

Although referrals for orthoses are often initiated

by physiotherapists, all orthotic prescriptions have

to be formally sanctioned by a doctor. In both dis-

tricts, an orthopaedic surgeon prescribes and, in

West Berkshire, paediatricians also sanction pre-

scriptions. However, this may be perceived purely as

an administrative procedure in some instances;

some prescribers conceded not being knowledge-

able about orthoses, and physiotherapists were

often influential on the choice of orthosis, as a pae-

diatrician in West Berkshire indicated:

‘I am advised by the physiotherapist at the Child

Development Centre’.

A community physiotherapist observed that the

actual prescription:

‘Often depends on the preferences of the budget

holder’.

Factors influencing orthotic prescription

Clinicians in both districts reported making col-

laborative decisions for prescribing orthoses, and

many involved the family in the decision. However,

the provision of consistent information appeared

unlikely, as respondents indicated using different

treatment paradigms and personal preferences. In

the absence of a clear and evidence-based prescrip-

tion protocol, therefore, the decision remains

largely a matter of opinion.An orthopaedic surgeon

described how:

‘Several disciplines are usually involved and

opinions on management of problems may

vary’.

Discussion

The populations of children with cerebral palsy in

each district were similar in gender mix, propor-

tions of bilaterally and hemiplegic spastic cases and

walking ability. There appeared to be differences in

the diagnostic classification and in the proportion

of children reported to have contractures in each

district. The difficulty in consistently classifying

children with cerebral palsy is a prevailing issue in

the epidemiology of the condition (Williams &

Alberman 1998). Although the European group has

simplified the procedure with a flowchart recently

(Surveillance of Cerebral Palsy in Europe 2000), the

findings in this study rely upon the criteria used

by various assessors since 1984. Possible reasons

for the increased reports of contractures in

Oxfordshire are that children in Oxfordshire are

more seriously affected, or it may result from the

higher proportion of children with spastic impair-

ments developing contractures more frequently.

Using data from both districts, there was an

increased risk of non-ambulant children develop-

ing contractures compared with children with any

walking ability. This finding, that the more severely

affected children may be at greater risk of defor-

mity, may be known intuitively but has not pre-

viously been demonstrated statistically. Some

children in each district will need more intensive

healthcare because of their increased risk of defor-

mity and disability. A measure of the severity of

activity limitations may now be more reliably



recorded using the Gross Motor Function

Classification System (GMFCS) (Palisano et al.

1997). Knowledge of the spectrum of activity limi-

tation using the five levels of the GMFCS will be a

more appropriate indicator for comparing popu-

lation needs for health services.

There is strong evidence from routinely collected

data that the prescription of orthoses for children

with cerebral palsy varies between the districts of

Oxfordshire and West Berkshire. Although some

variation in the physical management of individual

children would be expected as a result of the hetero-

geneity of the cerebral palsy diagnoses, the variation

in numbers and types of orthoses used in the two

districts goes beyond what would be expected in

similar populations. The variation in the use of

rigid ankle orthoses suggests that a predominantly

biomechanical programme has been delivered in

Oxfordshire and a more neurodevelopmental

therapy-orientated programme in West Berkshire.

The variations in orthotic prescription are an indi-

cator of the conflicting principles that underpin the

healthcare programmes delivered in the two dis-

tricts and a result of the lack of evidence to support

either treatment regimen. The survey findings must

be interpreted cautiously: the sample of clinicians

was derived from observation of the orthotic pre-

scription process by the lead author and, although

many clinicians were interested in the study,

respondents may have been those with stronger

preferences. The respondent validation process and

subsequent presentation of the findings to clini-

cians, however, supported our interpretation.

The survey illustrated the complexity of multi-

disciplinary team structures with different clini-

cians advising families in different locations.

Information that professionals provide to families

when prescribing orthoses was shown to be influ-

enced by individual preferences and hence incon-

sistent. This represents a formidable challenge.

Perhaps it is time to reconsider health service pro-

grammes for children with cerebral palsy using the

values and standards proposed by the European

Academy of Childhood Disability Working Group

on ‘Services for Children with Disabilities in

European Countries’. This report stated the impor-

tance of goal-orientated treatment programmes

adapted to the preferences of the child and family

and emphasized multidisciplinary team work and

co-ordination (McConachie et al. 1997). Identify-

ing the perceptions of families about the process of

healthcare delivery has highlighted the key issues of

information exchange, respectful and supportive

care and family professional partnership and

enabling families to make their own decisions

(Rosenbaum et al. 1992). Associations are evident

between these interpersonal aspects of providing

healthcare and client satisfaction, stress and adher-

ence to individual treatment regimens (King et al.

1996), the latter being particularly important if

orthoses are to be worn regularly within the family

setting.

Conclusions

There is a need for prescribers to identify the chil-

dren with cerebral palsy for whom the long-term

outcomes of specific interventions remain uncer-

tain. This can then be discussed openly with the

family. Further, as the ‘uncertainty principle’ is the

ethical foundation for randomly allocating differ-

ent interventions in clinical trials, is it indeed more

acceptable given the current inconsistencies?

The GMFCS will be used to define a spectrum of

activity limitation in complete populations and

could also be used to monitor baseline characteris-

tics between children receiving different interven-

tions in a clinical trial. Should further research be

attempted, collaboration between centres would be

necessary to conduct large enough randomized

controlled trials to detect the moderate differences

that are likely to exist between treatment groups

(Yusuf et al. 1984). This would ensure that the care

we provide in the future will be more evidence

based.

Acknowledgements

This study would not have been possible without

the interest and support of the members of the

project steering committee and the clinicians who

returned questionnaires. The research was part of

the thesis submitted by the lead author towards

the MSc in Evidence-Based Health Care at the

University of Oxford. I would like to thank my

supervisor Janet Harris, the teaching faculty and the



Orthotic Education and Training Trust who sup-

ported the tuition fees. The Management Group

of the Oxford Register of Early Childhood

Impairment (ORECI) approved the release of

register data for this study. ORECI is funded by the

South-East NHS Executive.

References

Audit Commission (2000) Fully Equipped. The Provision

of Equipment to Older or Disabled People by the NHS

and Social Services in England and Wales. Audit

Commission, London.

Bower, E. (1999) A guide to physiotherapy techniques in

cerebral palsy. Current Paediatrics, 9, 79–83.

Bowker, P., Condie, D.N., Bader, D.L. & Pratt, D.J. (1993)

Biomechanical Basis of Orthotic Management.

Butterworth-Heinemann, Oxford.

Centers for Disease Control & Prevention (1999) Frame-

work for program evaluation in public health.

Morbidity and Mortality Weekly Report, 48 (no. RR-

11), http://www.cdc.gov/eval (accessed 22/8/01).

Condie, D.N. & Meadows, C.B. (1995) Report of a

Consensus Conference on the Lower Limb Orthotic

Management of Cerebral Palsy. International Society of

Prosthetics and Orthotics, Copenhagen.

Condie, D.N. & Stewart, C.P.U. (1997) The orthotic

supply process. In: Orthotics (Orthopaedics and

Rehabilitation Technology Module). Distance Learning

Section, University of Dundee, Dundee.

Davidson, L.L. (1999) Evaluating child disability pro-

grammes: the role of commissioners. Child: Care,

Health and Development, 25, 129–139.

International Organization for Standardization. (1989)

ISO 8549-3: Prosthetics and Orthotics – Vocabulary,

Part 3: Terms relating to External Orthoses. ISO,

Geneva.

King, G., King, S. & Rosenbaum, P. (1996) Interpersonal

aspects of care-giving and client outcomes: a review of

the literature. Ambulatory Child Health, 2, 151–160.

McConachie, H.R. (1999) Conceptual frameworks in

evaluation of multidisciplinary services for children

with disabilities. Child: Care Health and Development,

25, 101–113.

McConachie, H., Smyth, D. & Bax, M. (1997) Services for

children with disabilities in European countries.

Developmental Medicine and Child Neurology, 39

(Suppl. 76).

McConachie, H.R., Salt, A., Chadury, Y., McLachlan, A. &

Logan, S. (1999) How do child development teams

work? Findings from a UK national survey. Child:

Care, Health and Development, 25, 157–168.

Morris, C. (2000) An Evaluation of Variations in Orthotic

Management within the Multidisciplinary Health Care

of Children with Cerebral Palsy in Oxfordshire and West

Berkshire. MSc Thesis, University of Oxford.

Morris, C. (2001) A review of the efficacy of lower limb

orthoses used for cerebral palsy. Developmental

Medicine and Child Neurology, (in press).

Palisano, R., Rosenbaum, P., Walter, S., Russell, D., Wood,

F. & Galuppi, B. (1997) Development and reliability of

a system to classify gross motor function in children

with cerebral palsy. Developmental Medicine and Child

Neurology, 39, 214–223.

Robards, M.F. (1994) Running a team for disabled

children and their families. Clinics in Developmental

Medicine, 130, Mac Keith Press, London.

Rosenbaum, P., King, S. & Cadman, D. (1992) Measuring

processes of caregiving to physically disabled children

and their families. 1. Identifying relevant components

of care. Developmental Medicine and Child Neurology,

34, 103–114.

Supan, T. & Hovorka, C. (1995) A review of thermoplas-

tic ankle-foot orthoses adjustments/replacements in

young cerebral palsy and spina bifida patients. Journal

of Prosthetics and Orthotics, 7, 15–22.

Surveillance of Cerebral Palsy in Europe (2000) A

collaboration of cerebral palsy surveys and registers.

Developmental Medicine and Child Neurology, 42,

816–824.

Williams, K. & Alberman, E. (1998) The impact of diag-

nostic labelling in population-based research into

cerebral palsy. Developmental Medicine and Child

Neurology, 40, 182–185.

Yusuf, S., Collins, R. & Peto, R. (1984) Why do we need

some large, simple randomized trials? Statistics in

Medicine, 3, 409–422.

variations in the orthotic management of cerebral palsy

Documents