Growing pains – adapting orthotic devices to maturing patients

Accommodating growth without compromising fit and function is a challenge for practitioners who prescribe orthotic devices for young patients. Adjustments and add-ons—as well as educating parents about expected changes—can make for smoother transitions.

By Shalmali Pal, Lower Extremity Review August 2015

YouTube is a treasure trove of feel-good videos featuring children walking for the first time with the help of O&P devices. There’s 2-year-old Kayden, 1-year-old Samantha, and 14-year-old Zoe, who lost her left leg below the knee in a jet skiing accident.

But these inspiring images capture only one moment in each child’s journey. What happens down the road as Kayden, Samantha, and Zoe mature and outgrow their devices?

The need to replace an O&P device on a regular basis has its challenges for practitioners, patients, and parents. The patient who has just become accustomed to a device has to start all over. Parents want the best for their children but know these replacements can come with a hefty price tag. And that means the practitioner must attempt to optimize fit and function for the moment, make adjustments over time if possible, and, ultimately, determine when a completely new device is necessary.

LER Pediatrics spoke with O&P experts on how to handle these issues, including how to accommodate growth without compromising fit and function.

While not a technical issue, patient and parent education is key to ensuring that everyone understands the purpose of a device and its projected longevity.

“We are always considering growth: How long can they wear it? What can we do to try to make it last longer?” said Leigh Davis, CPO, LPO, of Children’s Healthcare of Atlanta, and a board member of the American Academy of Orthotists and Prosthetists. “At the same time, since growth is so variable, you want to plan for what you see now rather than what might happen. You want to plan for care today versus planning for something that might happen in the future.”

Photo courtesy of Allard USA

Photo courtesy of Allard USA

Growth spurts
Of course, all children grow, but as Davis pointed out, not all kids grow at the same rate, even during infant, toddler, and adolescent years, which are known for growth. And children who require O&P devices often have compromised skeletal systems and musculature because of their underlying diagnosis, and that may affect their growth schedule.

Tony Wickman, CTPO, chief executive officer of Freedom Fabrication in Havana, FL, noted that bones tend to grow faster linearly than they do circumferentially. Unlike in adults, in whom changes tend to be more global, changes in kids may happen in a piecemeal fashion. For instance, a child may experience linear growth of the feet rather than medial-lateral growth, but without any major growth in the rest of the lower limbs.

Davis agreed that linear growth is more of a concern in kids who may not build muscle mass as quickly as typically developing children.

“So you don’t often see a really large increase in calf circumference in kids with certain disabilities,” she explained. “But let’s say their ankle-malleolar width increases so much that it’s painful to put the brace on or they can’t even put it on at all. They’d have to come in so that we could make adjustments to the device.”

At the O&P service at Ann & Robert H. Lurie Children’s Hospital of Chicago, Nikta Pirouz, CPO, and colleagues make ankle foot orthoses (AFOs) for children as young as a day old.

“Any presentation that requires an orthosis at that young an age requires a good fit even though these children aren’t ambulatory,” she said.

Many children who require O&P devices have underlying neurological conditions that can impact their ability to understand the purpose of the devices, use them properly, and express when the device is causing discomfort, possibly because of a change in body habitus.

Pirouz noted that standard clinical growth charts don’t really apply to kids who require devices, even if they don’t have underlying conditions.

“Even for typical kids, those charts are an aggregate. The chart will tell me where the child will be in a year, but it’s not going to tell me exactly when that will happen for each individual child. A week from now? Over the summer? That’s why follow-up is so important,” she said.

Finally, just as in the general population, childhood obesity is a problem in O&P patients. Pirouz pointed out that weight gain will most likely necessitate adjustments so that a device doesn’t pinch or dig into “redundant soft tissue.” But those adjustments don’t have to be complex.

“Whether it’s weight gain, or volume change that is part of the disease presentation, you can address that,” she said. “You can add a tongue to contain tissue. You can flare. You can pad. You can try interfaces to contain the tissue better.”

Photo courtesy of Allard USA

Photo courtesy of Allard USA

Don’t fit for the future
It’s not worth trying to fit a device for potential growth because it will compromise fit in the here and now, experts agreed.

“I want the device as fitted as much as possible to the child’s current shape and size,” Wickman emphasized. “What I don’t like to see is a big, sloppy fit in hopes that the child will grow into it. Then you lose control of the fit and possibly compromise the device’s
efficacy.”

Davis concurred. For example, she said she wouldn’t typically build extra padding into an AFO that could be removed at a later time, because that can add bulk and compromise fit. She would leave the footplate a centimeter longer than the toes to accommodate for growth—but no longer, as that can cause problems with tripping or may require a shoe that’s a size too big. Footplate size can be misleading to parents as well, she said.

“A lot of parents will rely on the footplate as a measure of growth. So if they wait [to replace the device] until the toes are hanging all the way over the footplate, then the height of the AFO becomes a concern,” she said.

Pirouz agreed that achieving maximum fit and function in the present is paramount. Adjustments for growth can be made, but in the right context.

“For instance, with a night AFO, the patient is not ambulating, so you can make that footplate as long as you want in order to accommodate for growth,” she said. “But if you think about the height of the device, that can only be so tall, otherwise it may make the brace uncomfortable.”

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