Serial Casting the Pediatric

Lower Extremity in the

Outpatient Setting
Lisa Davison, PT, MPT
Julie Hor t on, PT, MSPT

Copyr i ght ed m at er i al

Course Objectives
u The learner will state contraindications and indications for serial
casting in the outpatient setting with 100% accuracy.
u The learner will be able to utilize knowledge of cerebral palsy to
inform clinical decisions on the appropriateness of serial casting 100%
of the time.
u The learner will be able to utilize knowledge of idiopathic toe walking
to inform clinical decisions on the appropriate use of serial casting for
this population 100% of the time.
u The learner will feel comfortable with materials used for serial
casting in order to have the confidence to initiate this skill in the
outpatient setting.

What is serial casting?

u Conservative and non-invasive

u Therapeutic technique to correct soft tissue restrictions
u Therapeutic technique to provide appropriate
biomechanical alignment for optimal functioning
u Use of long term passive stretch to achieve functional
range of motion
u Assists results of botox injections (Dur sun et al, 2017)

u Can prevent or delay the need for orthopedic surgery

u Enhances orthotic interventions

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 Why Outpatient?

u Increased access
u Maximize timeliness of interventions (coordinating botox
injections, orthotic casting and fitting, bivalve fabrication,
family availability)
u Increased continuity of care
u Improved tolerance for casting procedures (patient
relationships)
u Family satisfaction with overall delivery of clinical care

Patient populations served by casting in

the outpatient setting
u Cer ebr al Palsy
u Down’s syndr ome
u Tr aumat ic Br ian Injur y
u CVA
u Muscular Dyst r ophy

u Spinal Cor d Injur y

u Spina Bifida
u Idiopat hic Toe Walking
u Foot Defor mit y
u Aut ism Spect r um Disor der

Who should learn to cast?

u Outpatient Pediatric Physical and Occupational

Therapists!

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 Indications for Serial Casting

u Soft tissue contracture

u Difficulty with fit of orthotic
u Decreased passive range of motion
u Decreased functional range of motion
u Decreased ability to achieve consistent heel strike during
gait
u Decreased ability to weight bear in standing

W o o sle y e t a l, 2 0 0 9

Contraindications of Serial Casting

u Open Skin
u Aller gies t o pr oduct s used
u Suspect ed st r ess fr act ur e; hist or y of non-union fr act ur e at sit e; r ecent
fr act ur e not fully healed
u Edema

u U ncont r olled int r acr anial pr essur e

u U ncont r olled hyper t ension

u Aut onomic st or ming, dysr eflexia

u Bony r est r ict ion of joint , har d end-feel
u Painful ar t hr it is at sit e

u N eed for limb access

u HO at sit e
W o o sle y e t a l, 2 0 0 9

Relative Contraindications
u Sensory defensiveness causing aversion to casting application or
removal process
u Skin sensitivity
u Excessive sweating
u Questionable compliance to cast care precautions/management

u Fixed contractures
u Red spots
u Difficulty keeping casts dry
u Decreased bone density at site
u Impaired circulation at site

W o o sle y e t a l, 2 0 0 9

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 Casting Plan of Care
u The length of casting will depend on the amount of range of motion
you are hoping to achieve with the casting and what joints you are
casting
u While guidelines are helpful, each child will have his/her own
individual plan of care
u Typically casting course will be 2-6 weeks.
u Casting will discontinue once goals are met, there is no change in
range of motion 2 weeks in a row or if there is skin breakdown
preventing reapplication
u Orthotic management needs to be addressed during the casting
process
u Ideally orthotics will be fitted after removal of last cast
u Bi-valves vs Night Time AFO’s
u Weekly PT and Home Program following casting

Post Casting Considerations

u The patient will have muscle weakness after casting.

u The parent needs to be aware that their gait pattern will
not have resolved post casting without follow-up therapy.
u You may discover weaknesses in other muscle groups once
new range is obtained
u These considerations also reinforce the benefit of casting
in the outpatient setting – you can continue with your
interventions during and after casting

Cerebral Palsy and

Serial Casting

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 What is CP?

Ø Group of disorders Ø Congenital or acquired

caused by injury to Ø UMN disorder
the brain
Ø Hyperreflexia
Ø Chronic Ø Babinski sign
Ø Non-progressive Ø spasticity
Ø No cure

ce re b ra lp a lsy.o rg .a u

Stats

Ø From 1.5 to >4 in Ø 50-75% have MR or LD

1000 live births Ø 30% have seizure disorders
Ø Most common motor Ø Modern birth practices are not
disability in childhood preventing CP
Ø Low birth weight Ø Increasing maternal age,
babies are 100 times increasing life saving measures,
more likely to IVF, multiple births, unknown
develop CP than factors
normal birth weight Ø Most lesions occur during the
babies second half of gestation (Wr ight et
al 2017)

cd c.g o v; n ih .g o v

What is spasticity?

Ø Velocity dependent resistance to passive stretch

Ø Spasticity ≠ Strength
Ø Increases over the first 12 months of life, and up
to 4 years (Wr ight et al 2017)

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 Tone/spasticity
Ø Mild/Moderate/Severe hyper or hypo
Ø Trunk, LE’s, UE’s
Ø Modified Ashworth scale (Campbell et al 2006)
Ø 0 to 4 with 1+
Ø Tardieu (1988) (Wr ight et al 2017) (Var gus-Adams, 2009)

Ø The Modified Tardieu Scale provides R1 and R2

Ø Spasticity angle = R1 - R2
Ø The greater the difference the greater the
benefit of spasticity management
Ø Used in standard serial casting and orthotic
assessments

Gross Motor Function Classification

System
Ø Originally published in 1997 to include a
description of motor function in bands up to 12
years of age
Ø Revised and expanded in 2007 to include motor
function band from 12 to 18 years of age (Palisano et
al, 2007)

Ø Great professional communication tool (Var gus-Adams,

2009)

Purposes of serial casting with CP

u Increase range of motion directly or indirectly

u Optimize fit of an orthotic
u Avoid pain
u Protect skin
u Allow for safe transfers
u Optimize seating and positioning
u Serial casting the LE is a GREEN LIGHT INTERVENTION!
(N ovak et al, 2013)

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 Typical postural presentations in spastic
CP
Ø LE: ankle PF, typically with
eversion, knee FLEX, hip
IR/ADD/FLEX
Ø UE: finger FLEX, ulnar deviation,
pronation, elbow FLEX, shoulder
IR/elevation/FL EX
Ø These represent typical contracture
locations and need for intervention s
Ø Abnormal muscle pull on developing
joints (Pax Lowes et al, 2017)

Many
Possibilities….

Typical bony presentations

Ø Posterior pelvic tilt

Ø Neuromuscular scoliosis, initially flexible
Ø Thoracic kyphosis
Ø Flared ribs
Ø Hip dislocation
Ø Shallow acetabulum
Ø Femoral torsion
Ø Patella alta
Ø Midfoot collapse
Pax Lowes et al , 2017; W r i ght et al , 2017

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 What interferes with the gait cycle in
CP?
Ø Pain
Ø Spasticity
Ø Contracture
Ø Co-contraction , grading
Ø Weakness
Ø Cognition
Ø Poor coordination and motor planning

Ø What do you need for effective single limb

stance?
Ø Good foot position
Ø Stability
Ø Sufficient ROM
Ø What do you need for effective swing
through?
Ø Effective push off (strength)
Ø Sufficient ROM
Ø Sufficient DF activation
Ø (Ross, 2007)

Ø How much DF do you need and where?

Ø How much KE do you need and where?

Diplegia
Ø Toe walking Ø Crouched gait
Ø Lack of heel strike Ø Lack of push off

Ø Toe drag Ø Overstretched soleus

Ø Collapsed midfoot
Ø HEELCORD
CONTRACTURE Ø HAMSTRING
CONTRACTURE
Ø Hip internal rotation
Ø Weak quads
and adduction
Ø Lack of knee extension
Ø Scissoring and hip extension
Ø Anterior pelvic tilt Ø Hip flexor contracture
Ø Medium guard UE’s Ø Elevated shoulders
Ø Tight lats

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 Hemiplegia
Ø Flexion on involved side Ø Extension on involved side
Ø Ankle eversion with Ø Lack of DF with
excessive DF
HEELCORD
Ø Lack of push off, unable to
isolate PF CONTRACTURE
Ø Knee flexion Ø Lack of heel strike
Ø HAMSTRING Ø Unable to isolate PF
CONTRACTURE
Ø Knee hyperextension
Ø LLD
Ø High guard UE Ø Retracted hip
Ø Lateral trunk flexion Ø LLD

Casting plan of care with CP

u Botox injections and timing of casting (N ewman et al, 2007; Boot h et al,
2003) – typical time frame is 1-2 weeks s/p botox
u Orthotic intervention – cast for orthotics when foot can be in the
desired functional position non-weight bearing; fit for orthotics when
casting is completed
u Bivalve fabrication – can use serial bivalves as casting progression, use
of bivalves vs night splints, timing of bivalve fabrication, use of
bivalves while waiting for orthotics to be revised
u Cast intervals – traditional method of weekly vs. more frequent cast
changes (Pohl et al, 2002)
u Additional casting – one side at a time? One joint at a time? Using
knee splints combined with ankle casting?

Optimal Alignment First

Ø ROM deficits
Ø Relationship of R1 and R2
Ø Serial casting, botox, night splints, HEP, muscle
releases
Ø Bony alignment
Ø Orthopedic intervention
Ø derotation osteotomies
Ø Muscle Function
Ø Orthotic intervention
Ø Kinesiotape, therapeutic garments

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 Alignment
for Function

Alignment for Function

Ø Beyond ROM (Cusick, 2011)

Ø Orthopedic considerations
Ø Adaptive equipment needs
Ø Orthotics - what kind, from whom, do they fit, are they
working??
Ø Coordination of Care

Idiopathic Toe Walking

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 Idiopathic Toe Walking
u Toe walking is bilateral and a persistent toe-toe pattern of gait.
(Sala et al 1999)

u Idiopathic toe walking (ITW) is a diagnosis of exclusion when a

child toe walks without any known medical condition (Williams et
al 2010; Sala et al 1999)

u The ITW diagnosis is used when there is no known etiology of

the toe walking and all other possible causes have been ruled
out (Williams et al 2010)
u Toe walking is consider an early variant of gait and should
resolve by age 2 (Sala et al 1999; Sut her land et al 1980)
u Delays for referral happen when when a pediatrician tells a
family their child will “outgrow” it

Toe Walking that is NOT Idiopathic

u Cerebral Palsy u Global Developmental

Delay
u Muscular Dystrophy
u Tethered Spinal Cord u Autism Spectrum Disorder
u Sensory Processing Disorder
u Hip Dysplasia
u Unilateral Toe Walking
u Leg Length Discrepancy
u Injury to the leg
u Stroke
u Tumor

Toe Walking

u Toe walking may be present in kids with many diagnoses

u Serial casting can be an effective intervention for toe
walking for gait training as well as improving range of
motion
u Understanding where the toe walking stems from helps us
determine a plan of care pre or post serial casting,
orthotic management and prognosis

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 Toe Walking Tool (Williams et al 2010)

u The Toe Walking Tool was developed to help rule out need
for referral to a specialist or another discipline for further
investigation of the cause of the toe walking.
u Toe Walking Tool discovered to be a reliable and valid tool
in the assessment of toe walkers
u The tool uses a series of questions to help determine
potential underlying causes of the toe walking.
u A “Yes” response to any question indicates a need for
referral back to the pediatrician and potentially a
specialist for further examination

Treatment of Idiopathic Toe Walking

u Traditional PT u Orthotic management
u Stretching u Daytime AFO’s with or without
wedging
u Strengthening
u Balance u Toe Walking SMO
u Carbon Fiber Foot Plates
u Gait retraining
u Proprioceptive training u Night time AFO’s
u Bivalved casts
u Sensorimotor Activities
u Serial Casting u Surgical Release

u Always followed by PT
u Orthotic Management

Evidence Based-Guidelines for Serial

Casting of ITW (Le Cras et al 2011)
u Intervention of serial casting if dorsiflexion range of
motion is 0 degrees (neutral) or less
u 0-5 degrees of dorsiflexion – traditional PT for 4-6 weeks,
if no change in range of motion then serial casting
u 5-10 degrees of dorsiflexion – serial casting not indicated

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new-9.pdf

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 Serial Casting of Idiopathic Toe Walking
u Serial Casting is considered a conservative option in the treatment
of ITW
u Studies have demonstrated that serial casting in children with ITW
has improved dorsiflexion passive range of motion
u A study in 2013 demonstrated no additional benefit of botox in
conjunction with serial casting in children with ITW (Engst r öm et al
2013)

u Current recommendation for serial casting is to wait until at least

child is 2 years old
u However, casting could be beneficial before 2 (Pist illi et al 2014)

Case Studies

Serial Casting
Demonstration and
Materials

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 Know your materials

Basic materials used for serial casting in

the outpatient setting
u Stockinette
u Foam Padding – many to choose from
u Cotton Webril
u Cast Material – Plaster, Fiberglass, Soft
u Cast Shoes
u Posting Materials
u Bivalve Materials
u Cast Cutter
u Good Scissors

Key points to remember

Ø It takes 2 people to cast, and this does not include the parent
Ø Always monitor your ROM and subtalar neutral
Ø Do not use a maximal stretch (Wiar t et al, 2008)
Ø Do not move back and forth from plantarflexion to dorsiflexion
Ø NO wrinkles please!!
Ø If you screw it up, redo it
Ø Be swift but not sloppy
Ø Perfect your own technique, try new things
Ø Use tight gloves

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GMFCS E & R between 6th and 12th birthday:
Descriptors and illustrations
GMFCS Level I
Children walk at home, school, outdoors and in the
community. They can climb stairs without the use
of a railing. Children perform gross motor skills such
as running and jumping, but speed, balance and
coordination are limited.

GMFCS Level II
Children walk in most settings and climb stairs
holding onto a railing. They may experience difficulty
walking long distances and balancing on uneven
terrain, inclines, in crowded areas or confined spaces.
Children may walk with physical assistance, a hand-
held mobility device or used wheeled mobility over
long distances. Children have only minimal ability to
perform gross motor skills such as running and jumping.

GMFCS Level III

Children walk using a hand-held mobility device in
most indoor settings. They may climb stairs holding
onto a railing with supervision or assistance. Children
use wheeled mobility when traveling long distances
and may self-propel for shorter distances.

GMFCS Level IV
Children use methods of mobility that require physical
assistance or powered mobility in most settings. They
may walk for short distances at home with physical
assistance or use powered mobility or a body support
walker when positioned. At school, outdoors and in
the community children are transported in a manual
wheelchair or use powered mobility.

GMFCS Level V
Children are transported in a manual wheelchair
in all settings. Children are limited in their ability
to maintain antigravity head and trunk postures and
control leg and arm movements.

GMFCS descriptors: Palisano et al. (1997) Dev Med Child Neurol 39:214–23 Illustrations Version 2 © Bill Reid, Kate Willoughby, Adrienne Harvey and Kerr Graham,
CanChild: www.canchild.ca The Royal Children’s Hospital Melbourne ERC151050
GMFCS E & R between 12th and 18th birthday:
Descriptors and illustrations
GMFCS Level I
Youth walk at home, school, outdoors and in the
community. Youth are able to climb curbs and stairs
without physical assistance or a railing. They perform
gross motor skills such as running and jumping but
speed, balance and coordination are limited.

GMFCS Level II
Youth walk in most settings but environmental
factors and personal choice influence mobility choices.
At school or work they may require a hand held mobility
device for safety and climb stairs holding onto a
railing. Outdoors and in the community youth may
use wheeled mobility when traveling long distances.

GMFCS Level III

Youth are capable of walking using a hand-held
mobility device. Youth may climb stairs holding onto
a railing with supervision or assistance. At school they
may self-propel a manual wheelchair or use powered
mobility. Outdoors and in the community youth are
transported in a wheelchair or use powered mobility.

GMFCS Level IV
Youth use wheeled mobility in most settings.
Physical assistance of 1–2 people is required for
transfers. Indoors, youth may walk short distances
with physical assistance, use wheeled mobility or
a body support walker when positioned. They may
operate a powered chair, otherwise are transported
in a manual wheelchair.

GMFCS Level V
Youth are transported in a manual wheelchair in all
settings. Youth are limited in their ability to maintain
antigravity head and trunk postures and control leg and
arm movements. Self-mobility is severely limited, even
with the use of assistive technology.

GMFCS descriptors: Palisano et al. (1997) Dev Med Child Neurol 39:214–23 Illustrations Version 2 © Bill Reid, Kate Willoughby, Adrienne Harvey and Kerr
CanChild: www.canchild.ca Graham, The Royal Children’s Hospital Melbourne ERC151050
Serial Casting of the Lower Extremity for Pediatric Physical Therapists

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