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, Fla. 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
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| © iStockphoto.com/derrideb |
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.”
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.” — by Anthony Calabro
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
