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Guideline Summary
Guideline Title
Evidence-based care guideline for serial casting of the lower extremity.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for serial casting of the lower extremity. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Jan 6. 12 p. [22 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Conditions associated with limitations of range of motion including, but not limited to:

  • Cerebral palsy (CP)
  • Traumatic brain injury (TBI)
  • Duchenne Muscular Dystrophy (DMD)
  • Idiopathic toe walking (ITW)
  • Spasticity
  • Decreased range of motion
Guideline Category
Counseling
Evaluation
Management
Rehabilitation
Treatment
Clinical Specialty
Family Practice
Neurology
Nursing
Pediatrics
Physical Medicine and Rehabilitation
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Occupational Therapists
Patients
Physical Therapists
Physician Assistants
Physicians
Guideline Objective(s)

  • To provide optimal skilled care to patients
  • To promote appropriate referrals
  • To improve functional outcomes
  • To decrease unwarranted variation in care
  • To improve patient/family satisfaction
  • To decrease/delay the need for invasive procedures

Target Population

Inclusions: These guidelines are intended for use in patients 0-25 years of age with limitations in range of motion or those at risk of limitations in range of motion (see the "Disease/Condition[s]" field).

Exclusions: These guidelines are not intended for use with patients with the following:

  • Skin surface not intact at the extremity to be casted
  • Uncontrolled hypertension
  • Uncontrolled intracranial pressure
  • Autonomic storming, dysreflexia
  • Marked edema at the extremity to be casted
  • History of non-union fracture or recent fracture at the extremity to be casted
  • Decreased bone density at the extremity to be casted
  • Bony restriction of joint, hard end feel at the extremity to be casted
  • Painful arthritis at the extremity to be casted
  • Need for limb access for monitoring vital signs and medication administration at the extremity to be casted
  • Impaired circulation at the extremity to be casted, including recent deep vein thrombosis
  • Heterotopic ossification at the extremity to be casted
  • Longstanding or fixed contracture at the extremity to be casted
Interventions and Practices Considered

Evaluation

  1. Indications for referral to pediatric rehabilitation
  2. Assessment for appropriateness for serial casting (see the "Target Population" field)
  3. Medical history, including Botulinum toxin injections, allergies/skin sensitivities, past casting/orthotics history
  4. Pain screen
  5. Assessment of range of motion, muscle tone, strength, posture
  6. Physical examination
  7. Assessment of functional skills
  8. Evaluation of patient/family precautions and factors
  9. Pre-procedure verification

Treatment/Management

  1. Serial casting (soft cast, reinforced soft cast, bivalved fiberglass cast)
  2. Patient/family education
  3. Home program activities
  4. Physical therapy consecutive serial casting assessment
  5. Discharge and follow-up
Major Outcomes Considered

  • Degree of passive range of motion of ankle dorsiflexion
  • Degree of passive range of motion of knee extension
  • Improvement in tolerance to passive manual stretching of affected extremity following each successive cast application
  • Change in ease of fit into ankle foot orthotics for positioning during rest, stance, or ambulation
  • Incidence of adverse effects of casting

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

To select evidence for critical appraisal by the group for the update of this guideline, the Medline, EmBase and the Cochrane databases were searched for dates of January 1970 to February 2007 to generate an unrefined, "combined evidence" database using a search strategy focused on answering clinical questions relevant to serial casting and employing a combination of Boolean searching on human-indexed thesaurus terms (MeSH headings using an OVID Medline interface) and "natural language" searching on searching on human-indexed thesaurus terms (MeSH headings using an OVID Medline interface) and "natural language" searching on words in the title, abstract, and indexing terms. The citations were reduced by: eliminating duplicates, review articles, non-English articles, and adult articles. The resulting abstracts were reviewed by a methodologist to eliminate low quality and irrelevant citations. During the course of the guideline development, additional clinical questions were generated and subjected to the search process, and some relevant review articles were identified.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Recommendations have been formulated by a consensus process directed by best evidence, patient and family preference and clinical expertise. During formulation of these recommendations, the team members have remained cognizant of controversies and disagreements over the management of these patients. They have tried to resolve controversial issues by consensus where possible and, when not possible, to offer optional approaches to care in the form of information that includes best supporting evidence of efficacy for alternative choices.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline has been reviewed and approved by clinical experts not involved in the development process, distributed to senior management, and other parties as appropriate to their intended purposes.

Recommendations

Major Recommendations

Each recommendation is followed by an evidence classification identifying the type of supporting evidence. Definitions for the types of evidence are presented at the end of the "Major Recommendations" field.

Therapist Training

  1. It is recommended that therapists providing casting care should have appropriate education, training and competence in casting and cast removal skills (Goga-Eppenstein, Philip, & Seifert, 1999 [E]; Cusick, 1990 [O]).

Assessment and Diagnosis

Referral

  1. It is recommended that the Division of Pediatric Rehabilitation be consulted when patients present with the following:
    • Decreased range of motion (ROM) in children who are diagnosed with cerebral palsy (CP), traumatic brain injury (TBI), Duchenne Muscular Dystrophy (DMD), idiopathic toe walking, etc.
    • More than 5 degrees difference is noted between R1 and R2 (Cusick, 1990 [O]). 

      Note: R1 is the point of resistance to maximal velocity stretch and is the dynamic range of motion.  R2 is the overall muscle length or muscle contracture and is slow passive range of motion (Boyd & Graham, 1999 [O]).

    • Persistent hypertonicity/spasticity (Goga-Eppenstein, Philip, & Seifert, 1999 [E]; Cusick, 1990 [O]).
    • Extremity cannot be controlled with splinting alone (Local Consensus [E]; Cusick, 1990 [O]).
    • Tightness in feet interferes with comfortable wear or improved function with ankle foot orthosis (AFOs)/shoes. (Local Consensus [E]; Cusick, 1990 [O])

Initial Evaluation

  1. It is recommended that Pediatric Rehabilitation physician/referral source and casting therapist assess whether the patient is appropriate for serial casting, using the inclusion/exclusion criteria listed above. If patient meets exclusion criteria, casting therapist will contact referring physician to develop further plan of care (Local Consensus [E]).
  2. It is recommended that a Physical Therapy Evaluation be completed including the components named in the table below. (Goga-Eppenstein, Philip, & Seifert, 1999 [E]; Local Consensus [E]; Cusick, 1990 [O]).

Table: Physical Therapy Evaluation

Patient Evaluation

History

  • Botulinum toxin injections sites and dates
  • Allergies/skin sensitivities
  • Past casting/orthotics history

Pain Screen

Range of Motion

  • Active
  • Passive (R1/R2)

Muscle Tone

Strength

Physical Findings (including skin condition)

Posture

Functional Skills

  • Gross Motor Function Classification System (GMFCS), if appropriate
  • Observational Gait Scale (OGS), if appropriate
Interventions

Type of Cast Fabricated

  • Soft cast
  • Reinforced soft cast
  • Bivalved fiberglass
Patient/Family Education
  • Purpose of serial casting and expected outcomes
  • Neurovascular checks
  • Emergent and non-emergent situations during serial casting
  • Cast doffing techniques for soft cast, if appropriate
  • Bivalved cast donning techniques, if appropriate
  • Activities to be addressed at home during serial casting, if appropriate
  • When to return for bivalved night splints, if appropriate
Plan and Recommendations
  • Additional Physical Therapy services
  • Orthotics
  • Continue with serial casting until range of motion goals are achieved
  1. It is recommended that prior to serial casting, the treating therapist consider the following precautions and patient/family factors:
    • Allergies or prior skin reactions to casting materials
    • Decreased sensation
    • Poor communication
    • Confirmed fracture healing
    • Excessive sweating
    • Sensory Issues
    • Poor compliance with cast wear (Goga-Eppenstein, Philip, & Seifert, 1999 [E]; Local Consensus [E]; Cusick, 1990 [O]).
  1. It is recommended that a procedure to ensure that the correct extremity and joint are being casted be utilized.

    Note: The Universal Protocol from the Joint Commission on Accreditation of Hospital and Related Organizations includes conducting a pre-procedure verification process, marking the procedure site and performing a time-out prior to the start of casting to minimize the risk of casting the wrong extremity.

  1. It is recommended that the patient/family be provided with written instructions detailing home management of the cast and follow-up therapy appointments.

Physical Therapy Patient/Family Education and Home Program Activities

Physical Therapy Patient/Family Education and Home Program Activities Following Initial Casting

  1. It is recommended that the therapist provide Patient/Family Education in safe home management and cast care to include:
    • Instructions for identifying emergency situations related to the cast that require immediate attention and may require removal of the cast
    • Instructions for routine monitoring for pain, circulation, skin condition
    • Instructions for monitoring condition of the cast
    • Instructions for  routine and emergency cast removal
    • Instructions for contacting therapist to ask questions or report concerns (Local Consensus [E])
  1. It is recommended that the patient/family carry out the following Home Program Activities throughout the casting program:
    • Sleep position on side with pillow between the legs
    • Play position in tailor sitting, long sitting, or kneeling with towel support under cast
    • Walking activities with cast shoes on; hamstring stretches
    • Standing activities for strength and balance (Local Consensus [E])
  1. It is recommended that ankle foot soft casts be routinely removed 24 hours prior to next casting treatment/application appointment to allow for bathing, stretching and weight bearing (Local Consensus [E]).
  2. It is recommended that the soft cast be removed immediately by parent via instructed method if the following occur:
    • Poor circulation in the casted extremity:  weak pulse, nail bed does not quickly return to its original color after being squeezed gently, cold to the touch, swelling
    • Evidence of or severe complaints of pain possibly indicating muscle spasms or skin breakdown, point tenderness
    • A cast that has become thoroughly saturated with water or fluids
    • Skin reaction such as rash, blisters, or abrasions
    • Unusual odor from cast (Local Consensus [E])
  1. It is recommended that if the following non-emergent situations are noted, the patient/family will contact the casting therapist:
    • Refusal to bear weight on casted extremity
    • Cracks/dents in cast
    • Changes for the worse in sleeping/mood
    • Dampness
    • Slipping in cast
    • Redness/chaffing without significant swelling or skin breakdown
    • Increased complaints of itching
    • Knowledge of objects dropped into cast
    • Unusual odor from cast (Local Consensus [E])

Treatment Plan

  1. It is recommended that at each consecutive casting session, the components named in the table below be assessed (Local Consensus [E]; Cusick, 1990 [O]).

Table: Physical Therapy Consecutive Serial Casting Assessment

Patient Evaluation

Pain Screen

Range of Motion

  • Active
  • Passive (R1/R2)

Muscle Tone

Strength

Physical Findings (including skin condition)

Posture

Functional Skills

  • Gross Motor Function Classification System (GMFCS), if appropriate
  • Observational Gait Scale (OGS), if appropriate
Interventions

Type of Cast Fabricated

  • Soft cast
  • Reinforced soft cast
  • Bivalved fiberglass
Patient/Family Education
  • Neurovascular checks
  • Emergent and non-emergent situations during serial casting
  • Cast doffing techniques for soft cast, if appropriate
  • Bivalved cast donning techniques, if appropriate
  • Activities to be addressed at home during serial casting, if appropriate
  • When to return for bivalved night splints, if appropriate
Plan and Recommendations
  • Additional Physical Therapy services
  • Continue with serial casting until range of motion goals are achieved
  1. It is recommended that successive removal, assessment and fabrication be repeated every 7 to10 days for 1 to 4 weeks. Additionally, casting may continue past the recommended 4 weeks if passive range of motion continues to improve (Cottalorda et al., 2000 [C]; Brouwer, Davidson, & Olney, 2000 [O]).

    Note: In patients with Duchenne Muscular Dystrophy, the duration of casting is 10 to 11 days with cast changes every 3 days (Main et al., 2007 [C]).

  1. It is recommended that casting be repeated as above until range of motion goals are achieved (Local Consensus [E]).

    Note: Normal range of motion goals are outlined in the table below (Cusick, 1990 [O]; Kendall & McCreary, 1983 [O]).

Table: Normal Range of Motion Goals

Normal Range of Motion Goals

Ankle dorsiflexion

  • <1 year: 45°
  • 1-4 years: 25°
  • 5-15 years: 10-20°
  • >15 years: 10-15°

Knee extension

  • By 5 years: 0°
  1. It is recommended that casting be discontinued prior to achieving range of motion goals at the discretion of the therapist discretion for the following possible reasons:
    • Decreased skin integrity
    • Allergic reaction
    • Decreased tolerance
    • Decreased safety
    • Less than 5 degrees of gain in range of motion over two weeks (Local Consensus [E]; Cusick, 1990 [O])

Physical Therapy Patient/Parent Education and Home Program Activities at Completion of Serial Casting

  1. It is recommended that the final cast be fabricated to be worn as a night splint (Local Consensus [E].

    Note 1: Ankle foot casts may also be worn during the day with cast shoes if daytime braces are not yet available. Stretching must be completed prior to donning. Bivalved ankle foot casts are applied with knee bent making sure that heel is down/back in bottom shell as far as possible. Skin check must be completed following doffing and 20 minutes thereafter to ensure that redness subsides (Local Consensus [E]); Cusick, 1990 [O]).

    Note 2: Bivalved knee extension casts are applied with knee as straight as possible and upper/lower leg down against bottom shell. The top shell must be applied, alignment checked and then straps tightened as much as possible without pinching (Local Consensus [E]). Skin check must be completed following doffing and 20 minutes thereafter to ensure that redness subsides (Local Consensus [E]; Cusick, 1990 [O]).

  1. It is recommended that after final cast removal that the following activities be completed by patient/family, unless otherwise indicated:
    • Nightly bivalved cast wear
    • Resuming ongoing physical therapy for strengthening and stretching
    • Pursuing short term physical therapy treatment for strengthening and stretching if it is not already in place
    • Heel cord and hamstring stretches
    • Balance and strength activities in standing (Local Consensus [E])

Discharge from Physical Therapy Casting Program

  1. It is recommended that following final cast removal, the patient is discharged with a recommendation for short term physical therapy trial for strengthening and stretching (Local Consensus [E]).

Follow-up

  1. It is recommended that the patient/family contact the therapist if they identify one of the following problems within in 1-2 months after the serial casting program has been completed:
    • Poor fit of the bivalved cast
    • Pressure areas on skin
    • Cast integrity

    A new bivalved cast may need to be fabricated (Local Consensus [E]).

Definitions:

M: Meta-analysis or Systematic Review
A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
S: Review Article
O: Other evidence
E: Expert opinion or consensus
F: Basic Laboratory Research
L: Legal requirement
Q: Decision analysis
X: No evidence

Clinical Algorithm(s)

The original guideline document contains the following clinical algorithms:

  • Patient eligibility for serial casting
  • Serial or bivalved lower extremity casting clinical guideline for casting patients with spasticity

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of evidence is classified for each recommendation (see the "Major Recommendations" field).

M: Meta-analysis or Systematic Review
A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
O: Other evidence
S: Review Article
E: Expert opinion or consensus
F: Basic Laboratory Research
L: Legal requirement
Q: Decision analysis
X: No evidence

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

  • Increased passive range of motion
  • Prevention of complications of deformity-producing positions
  • Allowance of future use of orthotics when needed
  • Promotion of highest level of function and mobility
  • Decreased/delayed need for invasive procedures
  • Improved patient//family satisfaction

Potential Harms

  • Decreased skin integrity
  • Allergic reaction
  • Decreased safety
  • Pressure areas on the skin

Qualifying Statements

Qualifying Statements

These recommendations result from review of literature and practices current at the time of their formulations.  This guideline does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document.  This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients.  Adherence to this guideline is voluntary.  The physician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

Tools to assist in the effective dissemination and implementation of the guideline may be available online at http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/default.htm External Web Site Policy. Experience with the implementation of earlier publications of this guideline has provided learnings which have been incorporated into this revision.

Implementation Tools
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for serial casting of the lower extremity. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Jan 6. 12 p. [22 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Jan 6
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Serial Casting Evidence Based Practice Team

Composition of Group That Authored the Guideline

Division of Occupational Therapy and Physical Therapy: Molly Woosley, PT, DPT, ATP, Division of Occupational Therapy and Physical Therapy; Rose Anderton, PT, DPT, Division of Occupational Therapy and Physical Therapy; Heather Blackburn, PT, MPT, Division of Occupational Therapy and Physical Therapy; Carol Burch, PT, DPT, Division of Occupational Therapy and Physical Therapy; Molly Mays, PT, MPT, Division of Occupational Therapy and Physical Therapy; Renee Vandemore Parsons, PT, DPT, Division of Occupational Therapy and Physical Therapy; Rebecca D. Reder, OTD, OTR/L, Senior Clinical Director, Division of Occupational Therapy and Physical Therapy

Division of Health Policy & Clinical Effectiveness Support: Kimberly Mason, RN, MSN, PCNS-BC, Guidelines Program Administrator

Ad Hoc Member: Douglas Kinnett, MD, Division of Physical Medicine and Rehabilitation

All Team Members and Clinical Effectiveness support staff listed above have signed a conflict of interest declaration.

Financial Disclosures/Conflicts of Interest

The guideline was developed without external funding.  All Team Members and Clinical Effectiveness support staff listed have declared whether they have any conflict of interest and none were identified.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on December 28, 2009.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Evidence-Based Clinical Practice Guidelines (EBCG) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of CCHMC's EBCG include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence-based care guidelines.
  • Hyperlinks to the CCHMC website may be placed on the organization's website.
  • The EBCG may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents.
  • Copies may be provided to patients and the clinicians who manage their care.

Notification of CCHMC at EBDMInfo@cchmc.org for any EBCG adopted, adapted, implemented or hyperlinked to by a given organization and/or user, is appreciated.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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