Long Term Serial Casting Evaluation and Explanation

Our appointment was for 11 a.m. I had to wake Gracie up to have her dressed and ready to go on time. We stopped at the gas station where I picked up a "healthy" breakfast of two donuts and a juice drink that was only 3% juice. As a precaution against her making a mess of herself, I had Gracie eat with her shirt off while I drove us in. Last time we went it took over an hour and a half to get there. This time I chose a different route with a brief detour when I incorrectly took I290 instead of I90. I quickly realized my mistake and returned us to the right route. It took us an hour and fifteen including the gas stop and getting lost. So looks like its the Kennedy Expwy for us in our future trips to Childrens Memorial Hospital Rehabilitation Center on Clark Street.

Mary Weck is the PT in charge of the long term serial casting program. We started the eval by meeting both Mary and Brigid, the orthoticist in charge of the program. Mary did the actual eval and talked to us in great detail about the program. I took movies with my digital camera using it mostly for the sound. Mary and Brigid are both terrific. They are enthusiastic and very attuned to Gracie and how she feels. I liked her and Brigid very much.

Her conclusions were as follows:

1. Gracie has a planter flexed forefoot on her right foot that needs to be stretched out. This could be congenital or developed in compensation for her tightness on her left side. But it needs to be addressed when we cast in order to put her in the correct alignment for learning how to walk correctly.

2. Gracie is at -20 R1 and -10 R2 with knee bent, -30 R1 and -25 R2 with leg straight.

3. Her hip flexors are slightly tight but equally so on both sides but its probably due to pattern.

About the program:

The theory of the program is that correct walking and use of the affected side will encourage growth and result in improved R1s and R2s. As circulation is built during the day due to the tension of being casted and being used on the affected side, growth hormones, which only kick in at night, cause the muscle to grow more on the affected side than it normally would. It helps her to level off and use both sides to promote symmetrical use and symmetrical growth of both sides. They never stretch her. They stop at her R1. Increasing the circulation increases the growth hormone. As her R1 increases, the casting angle increases. They cast her until she reaches +15 R1 and +20 R2 with knee extended. In addition, the PT and orthotist work together. There is no calling in of the orthotist. They make decisions together.

There are two phases to the program: the casting phase and the bracing phase. We begin with the casting phase.

CASTING PHASE
The casting phase can last anywhere from 6 to 20 weeks. There is no way to predict how long. A cast is put on each leg. There is no stretching at all. They only cast her to where she goes easily. If she is not growing well during the casting, they will have her wear a knee immobilizer during the night.

They want to make sure she is changing so make eight measurements every week. Three of these are circumference, range and strength. 2 cm change in calf muscle signifies an unacceptable level of atrophy. When that happens (its very rare), they take her out of the casts for 2 weeks, put her on a strength building program for two weeks and then try again. Strength is measured both "in pattern" and in terms of cerebral control where she isolates the muscle.

Every day at home we do "practice walking". The tightness was something that developed over time - not something she was born with. The way Gracie walks due to her tightness is to drop her left leg back a bit causing her to go up on her toes on the left side. Its a natural response to how she is aligning her body. They focus on changing her pattern of walking - to move her center of mass which naturally changes her to walking to on her heel. We will never go through the "put your heel down" fun. We are required to "practice walk" one hour each and every day. This can be done all at once or broken into chunks of any amount of time - the important thing is it adds up to 60 minutes. "Practice walking" will change every week depending on what we need to work on given how she looks at the beginning of that week. The better she gets at mass centering, the better her R1 and R2 measurements will be.

After she reaches the R1 and R2 goals, the casts come off. Then we move into the bracing phase.

BRACING PHASE

After the casting, Gracie will start wearing braces on BOTH legs 24/7. She will still do her 60 minutes of walking practice very day. After one month in the braces, they will begin weaning her off them. So,in the fifth week of being in the braces, she will be able to be out of them for 30 minutes a day. If she is still down when she walks, they will put her to 60 minutes a day for a week. If her heel starts to move up, she'll cut back to 15 minutes a day for a week. And so on. Cut back by half if we overstep it. Double it if it goes well. Sometimes, but not always, if they find her using her right more than her left, they will put a brace on her right side. Its somewhat contreversial but they have had good luck with that. It will depend on talks with Dr Dias, her orthopedic doc.

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The whole process usually takes a year for someone who walks as well as Gracie. By the time we hit next summer, she should be sufficiently weaned from her braces as to afford her good time for swimming,e tc. Tightness is not an issue - realignment will take care of it. She can do everything in the casts and braces that she does without them with the exception of anything that would make them wet.

After talking to Mary, we met with Brigid. Gracie was upset that she would have to be casted during Halloween and the two of them came in with photos (and slides!) of kids with the casts on made special for special occasions. They talked to her about what she wanted to be for Halloween (princess) and promised her pink princess casts. It was very kind of them. We first met Brigid when we saw Dr Dias last spring. That was our first glimpse of the program.

We are scheduled to begin casting at 8:00 a.m. on Monday, September 12th. Gracie will miss roughly 4 hours of school those days. I'll have to work it out with her 1st grade teacher. I had to drop two of my classes and reregister them as ONLINE classes. Both of them are math classes. I am very excited about it. I cant wait to talk to our PT about it.

Interesting fact: Only 30% of the people do the follow up protocol. It consists of wearing a night brace each and every night, and doing two strengthening exercise: 100 reps of going up on her toe and flexing her foot to bring her toes toward her. Those who did the followup 100% of the time, were 100% of the time successful at keeping their kids from going up on their toes again.

Another interesting fact: Mary and Brigid agree that Gracie should just stop wearing her current AFO. She is so tight there is no way to get her heel down into it and there is no reason to wear it at this point. Grace is absolutely thrilled to be brace free right now.



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