Effect of serial casting in spastic cerebral palsy

Indian Journal of Pediatrics, Volume 75—October, 2008 997

Original Article

Correspondence and Reprint requests : Dr. Navnendra Mathur,Department of Physical Medicine and Rehabilitation, RehabilitationResearch Centre, SMS Hospital, Jaipur 302004, Rajasthan, India.Phone : 91-141-2205474. Fax: 91-141-2620487

[Received August 12, 2007; Accepted April 10, 2008][DOI – 10.1007 / S12098–008–0100–2]

Effect of Serial Casting in Spastic Cerebral Palsy

Shweta Jain, Navnendra Mathur, Mrinal Joshi, Rajeshwari Jindal and Sunil Goenka

Department of Physical Medicine and Rehabilitation, SMS Hospital, SMS Medical College, Jaipur, Rajasthan, India

ABSTRACT

Objective. Cerebral palsy (CP) is a range of non progressive syndromes of posture and motor impairment due to an insultto developing brain. Spasticity and incoordination are major causes of disability in these children which can be managed bydifferent modalities like casting, botulinum toxin, surgery etc. Cast application in spastic equinus is a well established procedurein CP but cast application in patients of CP with bilateral involvement of hip, knee and ankle is not document.

Methods. A study was conducted on 22 children of spastic CP in age range of 3-8 years with bilateral involvement of hip, kneeand ankle in 20 cases, hip and ankle in one case and only ankle in one case. Sixty eight % children were spastic diplegics.Serial weekly cast with (11 cases) or without abductor bar (11 cases) was applied for four weeks. They were followed upvariably with an average period of 7 months.

Results. Significant improvement was noticed in range of motion around hip, knee and ankle which as maintained over hipand knee after average follow up. Spasticity was also reduced as measured by Modified Ashworth Scale (MAS). This ultimatelyimproved the ambulatory status and functional ability of these children.

Conclusion. Thus serial casting is a very simple, safe and cost effective procedure which can be applied even in children withmental sub normality having all three major joints involved bilaterally. [Indian J Pediatr 2008; 75 (10) : 997-1002] E-mail :[email protected]

Key words : Cerebral Palsy; Spasticity; Serial Casting

Cerebral palsy (CP) is the term for a range of non-progressive syndromes of posture and motorimpairments that results from an insult to the developingcentral nervous system.1 It may be associated with mentalimpairments2,3 seizures, sensory abnormalities,hydrocephalus, autonomic dysfunction, defects of visualperception4, 5 and learning disabilities.6

Spastic form of the disorder is the commonest.7

Spasticity presents with various positive (increased tone,increased deep tendon reflexes, persistent primitivereflexes, clonus, extensor plantar responses, discordantmass activation of muscles) and negative elements(decreased coordination strength and endurance).8 Itposes detrimental effect on activities of daily living,ambulation and overall development of these children.

Various modalities are available for the management ofspasticity.8 Cast application is one among others. It was

used as an adjunct to physical therapy in CP children.Short leg casts were found to be useful in increasing rangeof motion,9-18 tone reduction,9-11, 17-20 decreasing static anddynamic stretch,21 reducing resistance to passive stretchand dynamic reflex excitability,12 improving stride lengthand functional abilities10 along with providing stabilitywhile allowing mobility, initiating weight bearingactivities and improving motor skills.19,22 Statisticallysignificant changes in muscle tone11, 23 and functionalimprovement were not found by others.23 Tone reducingcast was found to be better option than standard one ingait improvement24 but, maintenance of improvementafter cast removal was found difficult in CP children.9, 13, 14

Still casting was rated as a safe simple procedureequivalent to other non surgical techniques.14

Physiotherapy along with casting was found to besuperior to physiotherapy alone.23

Various authors studied effect of Botulinum toxin inCP children. It was found more effective than casting15

while similar efficacy with both modalities was provedlater but Botulinum toxin was rated better by treatingphysician and parents.20 Recent studies reveal serialcasting more suitable than toxin17 whereas serial castingalone or with toxin was found to be better option fordynamic equinus in CP.18

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998 Indian Journal of Pediatrics, Volume 75—October, 2008

Above mentioned studies used casting for equinusdeformity in CP. But a case of adolescent CP who wasoperated previously for equinus deformity and presentedwith flexion, contracture at knee was reported forreduction of contracture and increase in range of motionaround knee by serial casting.25

Present study was conducted to evaluate the effect ofserial casting in spastic children in terms of increase inrange of motion, reduction of spasticity and improvementin ambulation in whom all three major joints (hip, kneeand ankle) were involved.

MATERIAL AND METHODS

The study was conducted in the Department of PhysicalMedicine and Rehabilitation, SMS Medical College, Jaipurfrom July 2004 to June 2006. During this period, CPchildren were evaluated in detail.

Those children (Fig. 1) who fulfilled the followingcriteria were included in the study:

• Age group of 3-12 years• Spastic diplegia, paraplegia or quadriplegia• Mental status normal or below normal but able to

follow instructions• Able to sit or stand with support• Grade II/III spasticity on MAS

With informed consent of parents, twenty two childrenwere given weekly cast for four weeks using custommade Plaster of Paris bandages. Groin to toe cast (20cases), cylindrical cast (1 case) and short leg casts(1 case)were applied with (11 cases) or without abductor bar (11cases) according to joints involved maintaining neutralposition over knee, mild dorsiflexion over ankle andextension over toe with extra padding done over pressurepoints. Abductor bar was applied such that it can beremoved and reapplied. On the second day of castapplication, child was made ambulatory with the help ofcustom made assistive devices (reciprocal walker orwooden tripod). Similar exercises were taught to everychild and their parents.

Once casting protocol was completed, joints weremobilized gently and every child was provided withcustomized static splints in the form of knee immobilizersand poly-propylene ankle foot orthoses (Fig. 2). Knee andankle exercises were added in the previous schedule andthe child was discharged. Follow ups were scheduledafter one month and then every three monthly.

Precast, postcast and on successive follow ups, range ofmotion (ROM) around hip, knee and ankle weremeasured using goniometer and measuring tape.Spasticity was evaluated using MAS. For ambulatorystatus, videography was done. Children were evaluatedafter dividing them into five categories according to theirabilities:

A. SittingB. Standing with supportC. Standing without supportD. Walking with supportE. Walking without support

Paired‘t’ test was employed to test differences in ROMat various joints in lower extremities between precast,postcast and average follow up values. Regardingspasticity, having qualitative data with less number ofcases, statistical analysis could not be performed.

RESULTS

Majority of children were males (77.27%), between agegroup 5-7 years (72.72%) and spastic diplegics (68.18%)(Table 1). Mental status of half of the children could notbe evaluated; in rest, 72.72% had mild mental retardation.Only thirteen children came for follow up with anaverage follow up of 7 months 5 days (range 1-20months).

TABLE 1. Type of Cerebral Palsy in the Children

Type Number of Patients

Spastic Diplegia 15 (68.18%)Spastic Paraplegia 5 (22.73%)Spastic Tetraplegia 2 (9.09%)Total 22 (100%)

Range of motion: Improvement in Thomas test aftercast removal from precast status was found to be highlysignificant (p<0.001) while after average follow up itdeteriorated to significant value (p<0.01) (Table 2).Abduction with hip and knee extension improved aftercast removal and was maintained in follow up to highlysignificant level. But abduction with hip and knee flexiondeteriorated immediately postcast due to stiffness and

Fig. 1. A spastic diplegic child standing with support



pain which improved a little in follow up. At bothoccasions, these changes were not significant statistically(p>0.05) (Table 3).

Highly significant improvement was noted after castremoval and in follow up in popliteal angle (Table 2).

Ankle dorsiflexion with knee extension as well as withknee flexion were improved immediately afterintervention to highly significant level but after averagefollow up, they deteriorated to non-significant level(p>0.05).

Spasticity: Majority of the children presented withMAS grade II and grade III spasticity over knee and ankle,respectively. 100% and 90.91% children showedimprovement over knee and ankle respectively, after castremoval. After average follow up period, 41.67% and33.33% children over knee and 38.46% and 46.15% overankle were able to maintain the improvement on rightand left side respectively. Except for one child, whoshowed improvement over ankle in follow up, all otherchildren deteriorated by one or two grades over knee andankle. But comparison of follow up from precast statuspresented different results. Over knee 25% and 41.67%children and 30.77% and 38.46% over ankle deterioratedto precast status on right and left side respectively. Rest ofthe children maintained improvement of one to threegrades over knee and ankle. None of the childrendeteriorated from precast status.

Ambulatory status: Thirteen out of twenty twochildren came for follow up and all of them showedimprovement in ambulation (Fig. 3). Out of ten childrenwho were in grade A precast, 10% children showedimprovement of one or two grades each. Three and fourgrade improvement was observed in 60% and 20%children respectively. One child of grade B showed twograde improvement. Two children who belonged to gradeE that is independent walkers remained in grade E but

they attained cosmetically and functionally a better gait.Scissoring, previously a big problem in these childrenresolved to an extent that they could ambulate easily.(Table 4)

Improvement in behavior of these children wasobserved and that might be the confidence they gained

TABLE 3. Mean Change ± SD in Abduction

Position of Limbs Stage Mean change ± SD Post p-value

Abduction with hip and Knee extension Post Cast 9.12±5.30 <0.001Follow up 9.44±4.64 <0.001

Abduction with hip and knee flexion Post 0.81±3.69 >0.05Follow up 0.89±4.17 >0.05

TABLE 4. Improvements in Ambulatory Status in Follow-up.

Follow upPrecast A B C D E

A 7+3* — 1 1* 4+2* 2B 1* — — — 1* —C — — — — — —D — — — — — —E 2* — — — — 2*

(*- mental status not available, rest with mental subnormality)

TABLE 2. Mean Change± SD in Various Parameters from Pretest to Various joints in Right Leg

Clinical Tests Right LeftMean change ± SD p-value Mean change ± SD p-value

Thomas test Post Cast 12.22 ± 9.58 <0.001 12.78 ± 8.78 <0.001Follow up 14.30 ± 10.82 <0.01 10.30 ± 10.79 <0.05

Popliteal Angle Post Cast 45.71 ± 11.75 <0.001 46.90 ± 14.36 <0.001Follow up 37.08 ± 18.27 <0.001 34.17 ± 13.45 <0.001

Dorsiflexion with Knee Post Cast 12.22 ± 8.78 <0.001 12.78 ± 6.00 <0.001extension Follow up 4.50 ± 9.26 >0.05 3.50 ± 7.09 >0.05Dorsiflexion with Knee Post Cast 10.55 ± 11.74 <0.001 9.72 ± 9.62 < 0.001flexion Follow up 0.00 ± 20.54 > 0.05 2.00 ± 18.74 > 0.05

Fig. 2. Immediate post cast standing with orthoses without support

S. Jain et al


after better ambulatory status. But, this improvement hadone deleterious effect as complained by parents andobserved by us that these children started avoidingexercises.

Physiotherapy is must with every intervention. Wefound that children with dedicated parents maintainedimprovement for longer time than those who did notfollow their exercise schedule regularly. Wooden tripodwas preferred more than reciprocal walker because ofease of walking with it, low cost and easy availabilityeven at their native places.

During the procedure, two complications wereencountered - Pain and Pressure sore. Pain was presentimmediately post cast and on mobilization after finalremoval of cast. Once they started ambulating, the painsubsided and child enjoyed their newly acquired status.Simple analgesics (NSAIDS) were given for 1 or 2 days.Pressure sore developed over heel area in 3 children.They were of grade 1 or 2 and improved in cast alongwith simple dressing when observed on next application.Two of the children later on switched over to surgery andwere not followed thereafter.

Botulinum toxin is used frequently in spasticitymanagement and is compared with casting.15-18, 20 It isuseful in focal spasticity but requires repeated doses.When all three joints are involved and child is not soyoung, use of Botulinum toxin can be a costly affair (U.S.$. 335/100 IU), whereas casting can be appliedsimultaneously for all joint inexpensively. With the use ofcustom made Plaster of Paris bandages, we can reducecost of casting further (U.S. $. 4.0).

Mental retardation is commonly associated with CP.We must assess the mental status of the child beforeundergoing any intervention. This is essential duringprocedure and exercise execution for their understandingand cooperation. Only few studies mentioned the mentalstatus of the selected children9, 10 and included childrenwith normal intelligence25 or adequate intelligence whocould understand the instruction.9 Only one studyincluded the children with normal, borderline, educableand trainable mental status.11 But, none of the authorshave clearly mentioned the outcome of their treatment inthe children with mental sub normality. In present studywe could manage to get evaluation of half of the childrendone by clinical psychologist. Out of these 11 children, 8and 1 showed mild and moderate mental retardationrespectively. Seven (7) cases in follow up showed clinicalimprovement as they were able to stand and walk withthe help of assistive devices. (Table 4)

Serial casting for progressive correction was appliedfor all three major joints simultaneously in most of thechildren in our study. Except for one case report of kneeflexion contracture,25 all other studies included childrenwith either equinus9, 11-24 or equinus deformity with mildinvolvement of hip and knee.10 Conservative manage-ment of scissoring was also not considered in thesestudies. We were able to achieve highly significantimprovement in range of motion around hip, knee andankle immediately post cast except for abduction with hipand knee flexion. This high statistical significance wasmaintained in popliteal angle and abduction with hip andknee extension even after average follow up. Thomas testimprovement became significant (p < 0.01), while changesin abduction with hip and knee flexion on both occasionsremained non significant (p< 0.05) (Table 2 and 3).Various other studies also showed increase in passiverange of ankle dorsiflexion immediately after castapplication.9, 10, 12, 13, 15-18 In our cases, both the parametersover ankle deteriorated from highly significant valuesafter cast removal to non significant in follow up. Thiswas in concordance with other studies11, 14 who followedtheir patients for 3.08 years and 5 months respectively.They opine that maintaining the correction postcast wasvery difficult. Non compliance in stretching exercises, inwearing orthoses and in coming for regular follow upmight be the reason for deterioration.

Present study showed decrease in grades of spasticity

Fig. 3. After 7 months follow up, standing without support.

DISCUSSION

In Developing countries where poverty, illiteracy andpaucity of health services are big problems; castapplication is a safe, simple and effective procedure forchildren with CP which can be applied at remote placeswith minimal facilities available.



as measured by MAS around knee and ankle joints.Though there was deterioration in follow up period fromimmediate post cast status, still ≥ 50% children maintainedtheir improvement. This is in correlation with otherstudies19, 10, 11, 15, 17, 20 but no statistical significance wasproved.11 Tardieu scale was found to be useful in showingimprovement in spasticity after cast application18 and notby Ashworth scale.23 We were unable to use MAS orTardieu Scale for measuring spasticity around hip. Wehave tried Tardieu Scale for spasticity at knee and anklejoints and found it difficult with children to measuredifferent angles with different speeds.

With increase in range of motion and reduction ofspasticity we could improve ambulatory status of ourchildren to a great extent (Table 4) which was differentfrom most of the other studies.9, 14, 17, 18, 20, 23, 24 In the presentstudy, around 76% children were unable to stand evenwith support while the above mentioned studies includedchildren with independent or assisted walking. Only fewauthors considered those children who were not able tostand or attained standing with support.10, 11, 17, 19

Cast application has its own drawbacks. If not appliedproperly it can lead to development of pressure sorewhich can be prevented by proper application of paddingand cast. Due to stretching of spastic muscle, there waspain initially which later on subsided with successive cast.This pain can be managed by simple analgesics.

Compliance of the children, dedication of parents andproper exercises are must for the success of any treatmentin cerebral palsy. Even orthoses and assistive devices playan important role in the attainment of set goals. We foundthat children with dedicated parents who regularlyfollowed their exercise schedule and used orthoses andassistive devices were able to maintain correction for alonger period of time.

For documentation of effectiveness of any treatmentmodality, a good sample size, regular and long follow-upare required. The shortest follow-up of 6 weeks12 andlongest of average 3.08 years14 were described inliterature. Because of large drop- out and variable follow-up period we could not find out the time whendeterioration started after casting.

We faced difficulty in measuring quantitative as wellas qualitative improvement of cast application in thesechildren. Though we used simple methods ofmeasurement like goniometry and photography;everything depended on the child’s mood. We tried timedwalking measure, nerve conduction studies for Hmax/Mmax ratio, Tardieu Scale, etc. but we could not make itwith these children. Illiteracy and unawareness of parentsposed a big problem for us to document their response.Therefore, we require some scale or measure designedespecially for these children of CP and an easilyunderstandable questionnaire which can be translated in

local language and used with equal efficacy. Above all,these should be accepted and acclaimed universally sothat various studies can be compared easily.

CONCLUSION

To our knowledge, the effect of casting in cerebral palsy inchildren with all three major joints involvement has neverbeen studied. With all its drawbacks like small number ofpatients, irregular and short follow up, more drop outs infollow up, absence of sophisticated measures and more; itis rather premature stage to draw a firm conclusion. Still,we think if properly applied, serial casting is veryeffective, safe and simple procedure which can be appliedat remote places with minimum cost in children with mildto moderate sub-normality and having all three majorjoints involved bilaterally.

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Effect of serial casting in spastic cerebral palsy

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