LOWER LIMB SERIAL CASTING
1. INTRODUCTION
Serial casting is a well-known, scientifically proven procedure used in the rehabilitation process of children with cerebral palsy, traumatic brain injuries, or Duchenne muscular dystrophy.
There are two types of casts: redressive and inhibitory. Redressive casting refers to a series of progressive casts (where the cast is changed periodically while simultaneously increasing the correction). These are used to increase muscle length. Inhibitory casts are used to normalize muscle tone and are usually applied only once.
In the course of neurological diseases, children may experience increased muscle tone, limited range of motion, or muscle stiffness within specific muscle groups. In the first phase, dynamic contractures appear. If not subjected to appropriate therapy and bracing, they can lead to static contractures.
The appearance of these symptoms in the lower limbs significantly affects the child's gait pattern, disturbing it and often making independent walking impossible.
Plaster casting is used to increase flexibility, stretch and lengthen shortened muscles, and improve muscle strength, which ultimately improves gait.
If your child walks on their toes, has a limited range of motion in the ankle joint, muscle stiffness, and an impaired gait pattern, read the further information and talk to your leading physiotherapist about introducing the casting procedure.
2. HOW DOES THE CAST WORK?
If a child has a limited range of motion in the ankle joint, it means that the muscle is too short, too weak, and not flexible enough to allow free movement of the bones in the joint.
The cast is applied in a neutral position (submaximal dorsiflexion with valgus correction), in which the muscle has minimal tension. This positioning of the joint and muscles allows the buildup of additional muscle cells so that the muscle lengthens and becomes more flexible. In our center, casts are applied for a period of 8 to 14 days, always on both lower limbs to maintain symmetry.
Since every child is different and presents a different gait pattern and disorders, it cannot be clearly stated that one casting will be sufficient. Serial casting may be necessary.
3. INDICATIONS FOR CASTING
- limited range of motion in the ankle joint
- difference of more than 5 degrees between R1 and R2 (Tardieu)
- persistent spasticity/hypertonia
- joint alignment disorders
- shortening of muscles, nerves, and ligaments
- risk of secondary deformations
- orthosis is insufficient to secure the limb
4. CONTRAINDICATIONS
Relative contraindications:
- allergy or previous bad reaction to the casting material
- sensory disturbances
- poor communication
- excessive sweating
- impaired bone tissue continuity
- fixed contracture
- sensory disorders (e.g., tactile defensiveness, low touch tolerance, etc.)
Absolute contraindications:
- impaired skin continuity
- bony limitations of mobility within the casted limb
- significant swelling within the casted limb
- need to use the limb to monitor vital signs
- hypertension and increased intracranial pressure
- autonomic nervous system dysfunction (storming)
- unhealed fracture in the casted limb
- osteoporosis in the casted limb
- circulatory disorders in the casted limb
5. BENEFITS OF CASTING
- pain reduction
- the procedure can be repeated many times
- increase in muscle length
- reduction of spasticity/increased muscle tone
- change in gait pattern
- increased tolerance of lower limb orthoses
- improvement of ankle joint alignment
- improvement of the support surface
6. WHAT ARE THE LIMITATIONS OF CASTING?
- lasts from 8 to 14 days and sometimes must be repeated
- can cause temporary and local muscle weakness
- the cast cannot get wet, difficulty during bathing
- pressure marks, chafing, or skin abrasions may appear
- in extreme cases, skin damage or pressure sores may occur
- in extreme cases, blood flow may be restricted or stopped
7. IMPORTANT THINGS TO CHECK
Circulation
It is very important to check circulation regularly. Press the tips of the toes; they should turn white and return to pink after 2 seconds. If the toes remain white, turn blue, or are cold or swollen most of the time, contact your physiotherapist; this may mean the cast is too tight and is disturbing the child's circulation. It may be necessary to remove the cast. To improve circulation, you can place your child lying on their back with their lower limbs elevated on a pillow. This position facilitates venous blood flow.
Sensation
If the child complains of numbness, tingling, or pain in the lower limbs, contact the leading physiotherapist as soon as possible. This may mean that the cast is pressing on nerves and must be removed immediately.
Pain
If the child persistently complains of pain and localizes it exactly around the ankle or heel, it may mean that the cast is pressing in that spot and there is a risk of a pressure mark or blister. Contact the physiotherapist immediately. If symptoms persist or the child cannot bear weight on the lower limbs, the cast will need to be removed.
Moisture/Sweating
It is normal for foot sweating to increase in casts, especially when the temperature is high. This can cause the skin to look white and moist, but it is not a problem unless the area is painful. If you observe such symptoms, contact the physiotherapist to assess the situation and take further action.
Itching
Itching under the cast is very common. The best way to relieve the sensation is to gently tap the cast. It is very rare for an allergic reaction to occur to one of the materials used. If your child has sensitive skin and you suspect an allergy, contact the physiotherapist to discuss the situation, as the cast may need to be removed.
8. CAST CARE AND BATHING
To maximize your child's comfort and safety during the series of casts, follow these recommendations:
- Avoid sand, loose bark, dirt, or gravel. They can get inside the cast, causing rubbing or pressure, leading to irritation or even pressure sores or wounds.
- Do not put any objects inside the cast. They can damage or tear the skin.
- Always put shoes on your child's cast. The cast is smooth and slippery; on some surfaces, slipping and cracking of the cast may occur. A cracked cast can damage the skin and disturb the gait pattern.
- Do not submerge the cast in water, even if covered with foil.
- During bathing, it is best for the legs to hang outside the tub/basin. For protection, you can wrap them in a double layer of cling film and place a plastic bag on top for extra protection.
9. HOW TO REMOVE THE CAST
The cast should be removed after 8-14 days. The leading physiotherapist decides when to remove the casts. Only they are authorized to remove them, as they have the knowledge and experience to do it safely.
Do not remove the cast yourself without consultation. It can be dangerous for both you and your child.
Before cutting, we remove all edge protections and cotton wool near the edge. We use pruning shears and bandage scissors to remove the casts. Two parallel cuts are made at the back of the calf along the lines behind the lateral and medial malleoli down to the heel. Then the cast is pulled back and the leg is removed.
We rarely use an oscillating saw due to the comfort of children who are afraid of the loud noise.
10. ACTIVITIES DURING CASTING / THERAPY
After applying the casts, the child cannot bear weight on the lower limbs for two hours. Lying and sitting positions are allowed. Standing and walking are prohibited. Premature weight-bearing on a cast that is not fully dry can lead to its breakage, resulting in therapy failure.
In the first phase, when standing and walking are allowed, let the child engage in their own activities (play, walk) to get used to the extra weight and shoe size. After the adaptation period (no longer than one day), we encourage daily activities. If you are careful and always use shoes or non-slip socks, there should be no limitations. You can support the stretching process by organizing play in standing or sitting positions. We advise against playing on the floor. Your physiotherapist will help choose and adapt activities.
Intensive physiotherapy is recommended, including gait training, treadmill training, stretching, strengthening of weakened muscle groups, and standing frames.
A child can go to school or kindergarten in casts. The condition for applying casts is undertaking intensive therapy. Without therapy, the casts alone do not provide satisfactory and long-lasting effects.
11. PREPARATION FOR CASTING
If you are preparing your child for casting or considering it, read this leaflet carefully and talk honestly with the leading physiotherapist. They should answer all your questions, resolve any doubts, and help you and your child prepare for the process.
Inform your child exactly what will be done. Speak about this form of therapy in a positive way. Show them photos/videos of other children. Explain that some things won't be possible for these 8-14 days.
Come to the appointment in loose pants and wide socks so they can be easily put on over the casts. The better you understand the topic, the better you will prepare your child, ensuring a stress-free process without complications.
12. WHAT TO DO AFTER REMOVING THE CASTS
After removal, orthoses should be worn for up to 10 hours a day; night orthoses are also recommended to maintain joint flexibility and secure the effect obtained during casting.
Intensive physiotherapy is essential. Children will not develop a new gait pattern on their own, even if their muscle and joint flexibility has increased. New skills must be trained and practiced.
Immediately after removal, wash and dry the legs thoroughly. Check for abrasions, pressure marks, or pressure sores. If everything is fine, let the child have a few minutes of free activity to get used to the new sensations and changes resulting from prolonged stretching.
Then, therapy can begin using all techniques and exercises. Intensive exercises strengthening the triceps surae and sensory stimulation are recommended. As a parent, you can perform a gentle massage or sensory massage of the calves and feet at home.
13. WHAT TO DO IF PROBLEMS OCCUR
During casting, you will have telephone contact with your leading physiotherapist. If you have questions or doubts, contact them. If you think something dangerous is happening and the cast needs to be removed, inform them immediately. Do not remove it yourself.
14. CONSENT FOR CASTING
15. ASSESSMENTS BEFORE AND AFTER
The decision is made by the leading physiotherapist based on an interview, observation, physical examination, and video gait analysis. Before and after, the therapist is obliged to measure the angle of spasticity (Tardieu), range of motion, skin condition, and record a video gait analysis.
Casts are applied in a prone position. The entire process takes about 60 minutes.
16. Price List
The full price for casting is approximately 700 PLN, but the total cost depends on the amount of materials used.