Orthotic management techniques for children with CP

Consider range of motion and alignment when helping children with cerebral palsy push functional limits.

A wise child once taught me, Never Say Never. AFOwear

by Anthony Calabro, Healio O&P News July 2011

The prevalence of cerebral palsy is approximately 2 or 3 per every 1000 births, according to Courtney Dunn DPT PT, a physical therapist in the Cerebral Palsy Clinic at Saint Louis Children’s Hospital. Dunn presented her evaluations of children diagnosed with cerebral palsy (CP), the importance of orthotic selection for the patients and how to problem solve and improve the function of children through orthotic management at the American Academy of Orthotists and Prosthetists 37th Annual Meeting and Scientific Symposium in Orlando, Florida. Her colleagues, Janice Brunstrom-Hernandez MD, Kathy Hernond PT, and Keith M. Smith CO LO FAAOP, were co-presenters of this session.

Range of motion
The goals of orthotic intervention are to increase the CP patient’s range of motion, maintain his or her level of functioning and/or improve his or her functional levels. Dunn described using orthotics as a tool instead of just an orthosis. In her clinic children are encouraged to push for their next level of function. Sometimes this requires increasing the support of a brace, allowing patients to work on strengthening, while giving them distal stability. In other cases, decreasing the support of the orthotic will allow patients with CP to achieve a new level of functional activity like running, jumping or walking with a walker instead of a gait trainer. At the clinic, the CP team sees their patients every 6 months and often changes orthotics after each visit due to their growth or hopefully their improved functional status.

“We use a lot of orthotics to improve range of motion,” Dunn told O&P Business News. “Dynamic strengthening and static progressive orthotics help the patient achieve range of motion. If you do not have range of motion, the patient cannot change movement. We really look at each child’s level of function and we look at what [his or her] goals are and what [his or her] family’s goals are.”

Oia has been using the new brace for about 2 weeks now and in true Oia fashion, she is tolerating it beautifully. Her gait is solid, and more stable now. This change in brace was the right recommendation. Her sweet feet will be in this arrangement of bracing until something changes again… because it always does. It’s just a matter of when. Righting Righty

Alignment
Along with range of motion, it is also important to evaluate the patient’s alignment. The physical therapist, orthotists and physician work together in managing the CP patient’s entire body. Saint Louis Children’s hospital works in a clinical team setting.

“I really do feel like an important piece is the team approach,” Dunn said. “We all have a different piece of the puzzle and it is important to listen to everyone’s subspecialties, making sure that the bones are in the right alignment and the range of motion is there to achieve what the orthotist wants to get out of the orthotic.”

Dunn talked about creating an orthotic as simple as putting a check strap on the back of a hinge brace so it can be used as a solid AFO and then, as the patient gains strength, he or she can make it into a hinged AFO just by loosening that strap. Dunn favors using hinges on the orthotic so it can be easily adjustable.

“We love to use orthotics in more than one way,” she said. “As the kids improve, you can change the role of the brace.”

Expanding uses
According to Dunn, orthotics and their ever-expanding uses have become popular at her clinic through the years.

“When I started practicing 16 years ago, we basically put kids in a SMO or hinged AFO, maybe a solid,” she said. “Now we feel like our range of choices with dynamic hinges, along with the options we have for foot plates, has been exponential even in only the past 5 years and that is really exciting.”

Still, Dunn and her clinical team are constantly trying to manage range of motion. They are always fighting the adductors, hamstring and gastrocnemius muscles’ range of motion. To combat this, orthotists have created dynamic stretching splints that can be used at night or during the day, depending on how the patient tolerates them.

“Range of motion is something we are always behind with kids with CP until they are finished growing,” she said. “Functionally with orthotics, we really try to make gait energy efficient, so the kids have the endurance to live the rest of their lives and support their highest level of function, without making them so fatigued that they can not use their function.”

Perspective
In our situation, we have a gait lab where we can study gait as a group and determine what orthosis or orthoses the patient should use. Sometimes we discover that we are going to slow the patient down with the brace. That is one thing we do not want to do. If they walk slower or worse with the orthosis, the patient will discard it. Then it becomes a compliance issue.

Energy efficiency implies oxygen flow to the heart and lungs. In kids, you do not see that as much with orthotics. It is more that the device is slowing them down. If they are slowed down, then they can not play with their friends as much or take part in activities. We do not describe it as energy efficiency. We see it as just trying not to slow the patient down.

— Scott Hosie CPO
Residency director, Shriner’s Hospital for Children, Salt Lake City UT

Source Healio O&P News

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