The value of a coordinated approach to patient care is widely acknowledged. That tenet is equally if not especially true when applied to O&P patient care. Its advantages are well illustrated by those applying the process when serial casting pediatric patients—whose long-term success may depend on the level of communication and cooperation between members of their provider team.
Serial casting is a series of progressive castings that correct toe-walking by reforming the foot by grades and degrees over time. Children and adolescents with cerebral palsy, muscular dystrophy, autism, and other conditions that affect a joint or muscle’s ability to flex normally can benefit from serial casting.
Shari Cassidy, PT, chief medical officer, Westside Children’s Therapy, Illinois, points out that “a lot of children with postural weakness and muscular imbalances are on their toes. These are the so-called idiopathic toe walkers that I don’t believe are idiopathic—their underlying postural deficiencies and muscular imbalances just haven’t been diagnosed yet. There’s always a reason why a child’s center of mass is in front of their base of support, and this displacement of the center of mass is the reason they’re walking on their toes.
“To achieve ideal outcomes, we work closely with our orthotists. After we determine how much range has been lost in the foot and ankle and the ideal end-range goal—which is determined by the age and activity level of the child—we can estimate the best time during the casting process to send the child to the orthotist for a molding appointment. From these molds a night splint and a daytime walking AFO will be fabricated with a specific design based on collaboration with the therapist. I and the orthotists on my team always use a very solid AFO design for postcasting children in order to fully control the position of the foot and ankle.
“Once the brace has been fabricated, and the child moves into a daytime AFO and a nighttime splint, we have a rehab therapist working with the child to develop muscular strength and cooperative cocontractions of the flexor and extensor groups to obtain proper postural alignment, which will direct their weight back toward their heels,” Cassidy says.
The gradual nature of the changes effected in patients makes communication between orthotists and therapists vital at each stage of the process.
“Since each child’s presentation is unique, the length of time needed to achieve the desired level of change varies from child to child, but age is a significant factor. Serial casting to correct a three-year-old’s issues may take three weeks as they have not laid down layers of connective tissue. Their range deficits have only been around for a short time. These children move quickly. The older the child and the longer the problems have been established, the longer the time required to correct them. We’ve worked with 16- and 17-year-olds that have laid down multiple layers of stiff connective tissue and presented with greater deformities within the foot, including the toes. These secondary deformities are often more challenging than the talocrural joint alone and can take nine months to a year to resolve.”
Cassidy points out that some of the responsibility for gaining range quickly lies with patients. The more steps they take each day and how correctly those steps are taken can speed up the process. Since proper stepping can promote length and strength, good communication between the serial casting team, patients, and their families is also a key ingredient of a successful outcome.
“I think that every serial casting patient and parent is encouraged and excited to know that progress is being made at each step along the way,” says Haley Ashley, DPT, PT, codirector of Physical Therapy, Westside Children’s Therapy. “That awesome communication that we have consistently with them lets them know that at some point they’re going to get their brace made; and at the end of this process, the bottom line and goal is that we have a child with beautiful feet, and they can start working on getting out of their braces.
“That takes, first and foremost, an open communication between both the physical therapist (or caster) and the orthotist. That communication must include the willingness and flexibility to make adjustments and necessary corrections along the way.”
Creating that pathway requires thoughtful steps.
“Our process requires us to send a patient-information form to the orthotist,” Ashley says, “describing exactly what we want made, where we want pads added, specifying where straps should be placed on the foot, whether the child requires a toe extension pad versus a metatarsal pad. Does the child need their calcaneus in neutral or a hint of varus, and what does that do up the chain of the child (i.e., pelvis, spine, trunk, head)? It all depends on the child.
“Prior to their appointment, we always send the orthotist an email reminder that our patient is coming to see them, and here’s what we’re looking for in the AFOs he or she needs. Typically, they reply to let us know that the fitting went well and raise any point they noticed that might need further discussion.”
This leads naturally to collaboration in the form of suggested approaches to possible improvements.
“We always know that if it doesn’t work, we can redo it. But both parties must be open to correcting mistakes and suggestions that failed in the implementation. As a PT, I would rather work with an orthotist who says, ‘It’s okay, we’ll redo it, we’ll remake it for you,’ versus ‘This is how it has to be!’”
Gila Baer, MPO, CPO, clinical specialist, BrainRobotics, also recognizes the importance of presenting parents of patients with a unified team who are all on the same page when it comes to their child’s case.
“From both the orthotic and physical therapy perspectives, we have found that having a full team understand the same basic research and the same rationale for providing our care is helpful in aiding the parents of patients to understand the motivation and embrace the process. It’s important to make sure that from an orthotics perspective, the physical therapists understand the approach that we’re taking and where we’re coming from—and vice versa. By doing so, we also enjoy a level of mutual respect and trust, acknowledging that we each know where our specialties lie, and what our training has enabled us to provide.
“We also understand that we don’t know everything, and that’s why we work with people who have greater detailed knowledge in areas that we may not have been exposed to,” she adds.
The serial casting choice itself often requires informed discussion between team members, Cassidy notes.
“Gaining range with serial casting is actually the easy part. The more difficult part for families is compliance with the postcasting protocol. The family needs to understand the range we achieve with casting must be maintained with compliant orthotic use. They also need to understand that a lot of rehab therapy is necessary to achieve proper alignment before any discussions of brace weaning can be had. 
“Many of the kids we see are involved and weak; they may have some spasticity or neurological involvement. A lot of these children have been walking with their center of mass in front of their base of support for a very long time, so they have a very difficult time getting their weight back. When we attempt to keep their weight back in a solid AFO, which holds the tibia in a more vertical position, it is initially much harder for the child because this requires them to activate their core, pelvic girdle, and leg muscles (glutes, quads, abdominals, etc.). This observed difficulty prompts some therapists to want to put them in a hinged AFO or an SMO [supramalleolar orthosis] because they believe the child can function better. In these types of braces, the child is able to incline their tibia, so their center of mass is in front of their base of support. There is very little regard for postural alignment and joint congruency.
“Over the long term, as they grow and add body weight, their tibia will continue to fall into greater incline and their function will decline as they become more crouched,” Cassidy says. “Once the tibia is inclined over 25 degrees, walking ability declines and these kids often end up in wheelchairs. So all therapists need to understand that while it may be harder for the child in the short term, it’s going to improve the child’s abilities in the long term. Since my goals are always focused toward their adult life, I strive to help my patients achieve a better postural alignment with joints as congruent as possible.”
A productive exchange of information about brace design and wearing schedules is sometimes impossible, she notes. “My team has been working together for over 40 years, and we have learned what works, as well as what doesn’t work. There are some doctors, orthotists, and therapists I no longer choose to work with because they don’t have an open mind.”
Baer, however, appreciates the value of such collaboration. “The biggest thing that has come out of working with the physical therapy teams really applies to many patients. Typically, in working with a different population and looking at serial casting, one of our goals would be to achieve some degree of dorsiflexion. And whether it’s pediatric or adult, we just want to eliminate plantarflexion contracture. Working with the expertise of Shari and her team, we found that through their knowledge of physiology and serial casting, combined with our ability to complement that through orthotic intervention, we were able to achieve a very large relative range of motion for dorsiflexion, getting over 20 degrees of dorsiflexion where previously we had come to expect and accept that achieving neutral was good enough.
“Especially relative to the pediatric population, we learned that you can achieve these greater ranges of motion, and we should be striving for that.”
Stages of the Process
The therapist’s blueprint or checklist for each patient’s orthosis is based on the initial therapy assessment. While the orthosis is being made, the therapy team proceeds with the casting, stage by stage, Ashley says. Although the orthotists they partner with are already familiar with the process, she encourages others to learn by observing the casting of a patient.
“When we are teaching a new orthotist, we’re always open, and invite them in to see what we’re doing. We’re going to have an orthotist here in two weeks that’s going to mold one of our kiddos in clinic, to see exactly what we want—as opposed to the patient going to the orthotics clinic.
“We also like to email the new orthotist to explain our protocols and request their input regarding the goals we’ve set for the patient. Braces cost thousands of dollars, and they need to be perfect for these children, so collaboration is essential.”
It’s not uncommon for minor changes to be required. Ashley estimates that eight out of ten patients typically return after a trial period with their braces, and report that they don’t feel good, or aren’t performing as expected.
“We frequently have to go back to get a pad readjusted or to get a strap placed differently, and sometimes the brace just has to be remade. The orthotists that we work with are always willing, kind, and generous, because they agree that it’s necessary. We just call or email the orthotist, and they say, ‘Okay, no worries. Bring it in and we’ll fix or adjust it.”
The consultations at any stage of the patient’s evolution are what lead to ultimate success, she points out, so Ashley’s team doesn’t hesitate to call other teammates and ask for insights when dealing with a specific patient issue: “‘What can we do to prevent the child from doing XYZ?’ we might ask an orthotist. And we welcome their input and apply it. You have to have an open mind receptive to collaboration and be able to share thoughts freely to get the best results.”
The Education Issue
“I think the current problem with serial casting is that a lot of people are going to a four-day course to learn to cast,” Cassidy says. “That’s just ridiculous. You cannot learn the proper casting techniques for all the varied deformities that quickly—I train my therapists for years before I allow them to cast the moderate or severe cases. It is concerning to me that the word going around the medical community is ‘therapists are breaking down children’s feet with serial casting.’ This is a problem, and it is time we start to change that narrative. 
“The key is having a skilled caster who is trained well and a skilled orthotist who really understands the bones and the muscles in the foot, and who is willing to change a brace if by chance it comes back less than perfect. So I work with a select few orthotists.
“Your goal as a practitioner should be to determine first what you’re trying to achieve, and then identify who you need on your team to bring this to fruition, and carefully select those team members.”
She attributes her team’s history of successes to her emphasis on selecting members who share her desire to achieve very specific goals for her young patients. The orthotists who have a similar desire and support her efforts to attain those goals are the ones she continues to work with.
The choice of rehabilitative therapists is more challenging, since some of her patients travel a significant distance to get casted and want rehab therapy nearer to their home.
“Because a therapist near the patient’s home might not be familiar with casting and a postcasting protocol, I’ll share with him or her our sequencing of our exercises as well as how to best progress the child,” Cassidy says. “I will discuss what the short-term and long-term goals are for the child. Then, and possibly most importantly, I want to make sure to provide guidance for the weaning process from the daytime AFO and night splint—we have a very specific way that we do this at our office. So I must train these therapists from a distance to know and implement the necessary protocol.
“I usually recommend these children come back to my ‘far away’ office every three months if possible. This allows me to assess how the child is progressing and determine if the treating therapist needs more guidance and direction to achieve our goals.”
Finding the Right People
How hard is it to find compatible people who have the skills and the willingness to work comfortably together?
“You definitely have to do a little bit of research,” Ashley says. “If you’re a PT, then you’ll research the orthotic clinics in the area, and call around and ask if they’re open to collaboration with a good brace for our postserial-casting kiddos—and if they would also be open to remaking it, if necessary.
“If you’re an orthotist, and you’re looking for a PT, you’ll want to find out if the PT is open to learning how to cast, learning that collaboration of emailing, calling, and texting in order to find solutions for a child whose brace might not be fitting right. The PT and the family are the first ones to know if a brace isn’t fitting well, or if they’re growing out of it.
“So that good relationship is essential, and it does take time to build. It definitely took some time to find the good ones we have in our clinic—as well as some that were not such a good fit.” she recalls.
Baer recommends talking to other trusted people in the field to find out if there’s a physical therapist in the area who is familiar with working with the O&P population at local rehab facilities.
“I am fortunate to have trained under leaders in orthotic management of toe-walking, especially Don McGovern, CPO, FAAOP, and to have longstanding relationships with expert physical therapists, such as Shari. Always utilize your mentors and their experience.
“Visits to local rehab facilities, building relationships, and trying to be an active player are all helpful methods. Offering education to nearby OT schools or medical schools, exposing them to what we do as prosthetists and orthotists, and building those connections are also good ideas. During the process, we can learn who are the available resources around us, and at the same time I talk to the patients coming in. If they’re getting physical therapy and they like their therapist, I can suggest they encourage the physical therapist to give me a call if they have questions about their progress and let them know we are open to knowledge sharing.”
Although sometimes it takes a while, she counts multiple times throughout her career when she has received calls because of patients who have passed on this information to their providers.
The right people to be team players, Ashley explains, have the heart and the learning and the will to change a child’s life for the better.
“Everybody makes mistakes; that’s how we learn. But are you willing to fix them? Some people are not. There are a lot of individuals in this profession that have egos that make them inflexible—it’s their way or no way. We want the best for each child, and the child deserves our best. It’s okay to make mistakes but fix them for the child’s benefit.”
Cassidy likewise emphasizes the commitment to learn from the other players in the collaborative group.
“We have to be willing to listen and learn things. None of us is right 100 percent of the time. If there’s a disagreement, both parties should explain how their train of thought has led them to their conclusion. Sometimes when you hear the opposing train of thought, you’ll learn that it’s possible you could be wrong.
“It requires a lot of give and take, but what I see in some places where this collaboration breaks down is that it’s often an attitude or an ego that gets in the way of learning. If we keep an open mind and a willingness to learn from others with different opinions, that’s where we really grow.”
Setting up Your Own Serial Casting Team
“I have spoken to many knowledgeable orthotists from different parts of the country,” Cassidy notes. “They’re struggling to develop a successful casting program. It’s a challenge for them to get therapists on board with what they’re trying to accomplish; it seems like the orthotists I have spoken to might know a bit more than some therapists about postural alignment and congruency of the foot. If these skilled orthotists really want this collaborative approach, they will need to find therapy members who are open-minded and willing to learn from the orthotists.”
Baer says that “it’s always beneficial to maintain relationships with others because you never know when you may be on a team. At the same time, some teams happen by chance. As long as all parties approach it from a perspective of sharing information, recognizing the value that someone else can bring, I think it can be highly successful.”
“The main ingredient for a successful team is true collaboration,” Ashley advises. “It relies on building a positive, trusting relationship based on a commitment to do what is best for the child. It’s going to take some time to build such a team—time, patience, and good skills. But having that wonderful, loving, heartfelt relationship with our orthotists is so worthwhile. I love talking to them, and we talk every week; they’re like family for our company, and we’re so lucky to have them. And there’s always room for one more on the team.”
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.
Opener and convo bubbles: vegefox.com/stock.adobe.com
Tip Toes: Towfiqu Barbhuiya/stock.adobe.com
