SLR - July 2017 - Sohan P. Patel

Randomized Controlled Trial on Effectiveness of Intermittent Serial Casting on Spastic Equinus Foot in Children with Cerebral Palsy After Botulinum Toxin-A Treatment

Reference: Dursun, Nigar MD; Gokbel, Tugba MD; Akarsu, Melike BA; Dursun, Erbil M. Randomized Controlled Trial on Effectiveness of Intermittent Serial Casting on Spastic Equinus Foot in Children with Cerebral Palsy After Botulinum Toxin-A Treatment. Am J Phys Med Rehabil. 2017 Apr 96(4):221–225.

Scientific Literature Review

Reviewed By: Sohan P. Patel, DPM
Residency Program: Northwest Medical Center, Margate, Florida

Podiatric Relevance: Spasticity is a common cause of secondary complications like contractures and bony deformities. Spastic disorders are commonly seen in patients with cerebral palsy (CP), most frequently being that of spastic equinus. Traditionally, to manage the spasticity and contractures in these patients, serial casting was used in conjunction with Botulinum toxin-A injections. Recently, there has been some argument about the reliability of the serial casting protocols and the complications that can follow in their application. This study is a small-randomized controlled trial of 51 patients aiming to show the effectiveness of intermittent serial casting in conjunction with physical therapy and Botox-A injections.

Methods: A level IV randomized controlled study was conducted on juvenile cerebral palsy patients who were ambulatory at the time of the study. The patients had been previously treated with Botox-A injections for spastic equinus foot. A total of 51 patients were randomly assigned to either the casting group or to the control groups in a 2:1 ratio. Both groups received physical therapy for three consecutive weeks, with the casting group receiving serial casting intermittently for three weekends in conjunction with the therapy. Prospective outcomes were assessed by using Passive Range of Motion (PROM) and the Modified Ashworth Scale (MAS). Secondary outcomes were based on the Tardieu Scale, Observational Gait Scale and Physician Global Assessment at baseline and then at posttreatment weeks four and 12.

Results: The casting and control groups both saw improvement with significant statistical increases in PROM, MAS, Tardieu Scale and OGS. The casting group also saw statistically higher averages at week four than the control group in MAS, PROM, angle of catch and OGS. The follow-up Physician Global Assessment at posttreatment weeks four and 12 also favored the casting group. No adverse effects were accounted for in the control group, while short-leg cast breakdown occurred in one patient in the casting group.

Conclusion: This prospective, randomized, controlled study revealed significant benefit when incorporating serial casting with PT and Botox-A injections. It is possible that the serial casting allows for reduction in spasticity as well as greater increases in passive range of motion and improved gait function. The study was limited in its number of participants, and further large-scale studies should be done to validate the results. The study was blind in nature; some bias is likely inherent to the casting process. The results of this study support the use of serial casting in the management of spastic equinus.

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