Kirsty Stewart, Christine Chapparo

This paper is derived from a presentation at the OT Australia AAOT-NSW, 6th State Conference, Mudgee, NSW, (1993, October)

KirstyStewart, MAppSc(OT), is a lecturer in the School of OccupationalTherapy, The University of Sydney, NSW.

ChristineChapparo, MA,DipOT,OTR,FAOTA, is a senior lecturer in the School of Occupational Therapy, The University of Sydney.

INTRODUCTION

Combinations of spasticity, dyskinesis and reduced isolated control are found in almost every child with cerebral palsy. This abnormal tone and movement can seriously interfere with upper limb motor performance in young children. The resulting malalignment of joints and abnormal pattern of muscle action affect the quality of fine motor control required for prehension and bilateral use. This in turn reduces the repertoire of reach, grasp and release patterns available to the child for everyday occupational performance tasks.

Occupational therapists who provide direct service to young children with cerebral palsy seek to improve the quality of upper limb movements during the performance of occupational tasks. As an adjunct to play and work related modes of intervention, therapists often apply various upper limb orthotic systems to encourage the carryover of gains made in therapy.

Controversy has existed for many years over the use of casting as an orthotic system to manage young children with cerebral palsy. Therapy literature reveals little support for upper limb casting, reflecting instead, occupational therapists preference for the use of thermoplastic orthoses. Few articles exist to support the clinical impression that casting of the wrist improves active wrist and hand control in children who demonstrate active and functional motion.

The purpose of this paper is to present case studies that illustrate the results of a serial inhibitory casting program for two preschool children with cerebral palsy.

LITERATURE

Serial inhibitory casting, when used as a treatment approach for people with cerebral palsy, has two main aims. One aim is that of reducing and preventing contractures for positional or health reasons and the other is to improve active upper limb occupational performance. Casts may also be applied as a pre-surgical trial ( Tonkin, 1995) or to increase the use of the affected upper limb by casting the unimpaired arm (Yasukawa, 1990).

Inhibitory casting to reduce contractures caused by abnormal tone is no longer a novel treatment and occupational and physiotherapists frequently apply casts to the upper and lower limbs for this reason (Barnard, Dill, Eldredge, Held, Judd & Nalette, 1984; Booth, Doyle & Montgomery, 1983; Cherry & Weigand, 1981; Cruickshank & OÌ“Neill, 1990; Hill, 1994; King, 1982; Kitson, 1991; Smith & Harris, 1985; Steer, 1989; Tona & Schneck, 1993). However, the use of serial inhibitory casting to improve active wrist and hand control in children who demonstrate active and functional movement is not as well supported in the literature (Chapparo & Stewart, 1993).

A study by Yasukawa (1990) found that ‘the use of inhibitory upper extremity casting can enhance function and improve arm-hand position” in a child with hemiplegic cerebral palsy. Law et.al. (1991) also found that serial casting, in combination with intensive therapy, improved hand function in children with cerebral

palsy. At the Spastic Centre of NSW, occupational therapists have also found that serial inhibitory casting is most effective in improving upper limb function in children with cerebral palsy (Chapparo, 1992).

RATIONALEFOR CASTING

Disturbances of active wrist and hand function in children with cerebral palsy occur as a result of four primary problems:

1.Muscle spasticity commonly pulls the upper limb into a posture of flexion. the muscular tension produced by the spasticity increases when the muscle groups are stretched during the performance of occupational tasks.

2. Abnormal synchronous activity or cocontraction occurs between specific muscle groups during rest or when the muscles are acting as antagonists. A typical finding is the persistent activity of the flexor muscles of the wrist, particularly flexor carpi ulnaris when finger and wrist extension is attempted.

3. Hyperactivity of the stretch reflex mechanism is produced byfailure of the normal muscle lengthening reaction to elongation by sudden stretching. This causes a stereotypic flexion patterning of the wrist during hand function.

4. To a lesser extent in children with active wrist motion, myostaticcontracture occur.

We have found that wrist casting is effective in altering this pattern of dysfunction within a short space of time. It has many advantages over more traditional orthotic devices. Yasukawa (1990 & 1992) outlined four main advantages of the use of serial inhibitive casting to improve function in the upper limb. The first is that joint stability can be improved, encouraging the client to use the affected arm during bilateral activities. Second, casting anatomically aligns the limb and thus may strengthen opposing muscle groups. Third, improvements in the overall balance of the flexor and extensor muscles may occur due to the additional proprioceptive input from the cast and fourth, the impaired upper limb may be trained to function more efficiently. Other benefits of casting include: the maintenance of a prolonged, gentle stretch to spastic or contracted muscles; 24 hour a day biomechanical intervention; the gradual increase in range of movement from the serial application of casts; and circumferential pressure and the warmth of the casted limb.

As with any intervention, the effectiveness of a casting program is based initially on the appropriate choice of child for casting. The majority of casting literature outlines the various criteria the researchers used in the selection of candidates for their casting programmes. Copley, Watson-Will and Dent (1996) presented indications and contraindication for casting selection based on the current literature by Booth, Doyle & Montgomery (1983); Cusick & Sussman, (1982) & Steer (1989). The indications for casting included: the existence of soft tissue contractures; limitations in active range of motion; difficulty in orthotic application for tone reduction and difficulty in achieving or maintaining weight bearing positions for tone reduction. The contraindications outlined included: the presence of rigid tone in the upper limb; the presence of fluctuating tone; medical instability; joint calcification and existing skin

conditions.

Candidates for casting can be classified according to a number of criteria. Chapparo and Ranka (1994) developed one classification system that grouped clients into two categories, Type 1 and Type 11 and the goals of the casting programs can be related directly to these groupings (See Table 1).

The type 1 casting candidates are generally the clients presenting with little or no active movement in the upper limb, poor or absent sensation and they tend to be fully dependent in activities of daily living. The abnormal upper limb patterns are usually well established and the clients often have an intellectual disability together with the physical disability. The main goals of casting with the type 1 candidates are tone reduction, to gain biomechanical and musculoskeletal changes, for health and hygiene reasons and to improve upper limb positioning. The casting program is generally non-functional and can be viewed as an annual or biannual upper limb management program.

Type 11 casting candidates are generally more functional, have some active range of movement and use their affected upper limb spontaneously. There is usually little or no sensory impairment. These clients are usually young, from 18 months to 8 years or the upper limb impairment is relatively recent. In most cases the clients are developmentally appropriate and are able to understand the goals and process of the casting program and participate in the program. The

main goals of casting with type 11 candidates

CRITERIA	TYPE 1	TYPE 11
MOTOR	little or no active motion	significant to isolated active ROM, spontaneous use
SENSATION	impaired or absent	very mild impairment to normal
NEED	positional, health & hygiene	increased function
AGE / ONSET	well established abnormal patterns	young or soon after onset of abnormal pattern
CARE	total or significant care	parental care or independent
BEHAVIOUR/ COGNITION	decreased cognition/behaviour increased agitation	developmentally appropriate understand goals and process able to engage in active program

Table1:Type I and Type II criteria

are to increase or improve active function in the upper limb, increase active and passive ranges of movement and reduce tone. Improved occupational performance is usually seen in the form of improved reach, grasp and release, improved bilateral usage and increased use of the affected upper limb as an assist.

The majority of clients will not fall completely into one or the other categories, but will have some aspects of both. Clients being cast for improvement in function will present with mainly type II characteristics and the clients being cast for contractures, health and positional reasons will have mainly type 1 characteristics.

THESELECTION OF TYPE 11 CASTING CANDIDATES – CASTING TO IMPROVEOCCUPATIONAL PERFORMANCE

In the absence of a well defined protocol for upper limb casting for function as an occupational therapy intervention, it was necessary to build upon well established existing allied protocols. The Spastic Centre of NSW applies similar criteria to those used for upper limb reconstructive surgery to casting candidates, as there is evidence that these prerequisites are appropriate when selecting candidates for casting aimed at promoting functional improvement. Upper limb surgery and serial casting can both be classified as biomechanical forms of intervention in that they are designed to change the structure and balance of musculoskeletal function of the wrist and hand and both aim to improve the function as well as the appearance of the limb. The following criteria are used to

determine appropriateness of clients for casting to improve wrist and hand function.

a.Voluntary Control: This refers to the amount of voluntary motor control at the joints to be cast. We propose that prognosis for improved wrist and hand function would be optimal for those children who demonstrate spontaneous use of their involved arm as well as wrist extensor strength of above 3.

b.Sensation: Sensory impairment may be a limiting factor for the functional motor outcome expected from therapy, surgery or casting. The general proposition is that the degree of spontaneous upper limb use parallels the degree of sensory awareness. If the arm is ignored, then sensation is usually poor. The best outcome from casting would therefore be found in children with good discriminatory sensation.

c.Age: Althoughcasting can be successfully implemented as young as 15 months, we believe the best candidates for casting would be between 3 and 5 years of age. At this age it is felt that the child is old enough to participate in their own programs and understand the procedure. Older children tend to have developed compensatory patterns and are less likely to be receptive to new ways of learning to use their upper limb.

d.Motivation and Need: Casting, as with other interventions, is most successful with those children who enjoy activities and demonstrate the ability to co-operate in performing motor activities on command. At the same time however, we believe that there has to be an

intrinsic functional need for improved motor control. If the child and parents do not identify a functional need they will probably not persevere with a casting program.

e.Informed Parents: Parents are an important part of a childÌ“s casting program and as such it is vital they have realistic expectations of the goals of casting. The main expectation for parents is that they will be able to encourage their child to continually use the casted limb in a manner that will enhance the outcome.

CASEDESCRIPTIONS

Two preschool aged children with cerebral palsy were selected as appropriate candidates for serial wrist casting, both presenting as Type II casting candidates. At the time of this intervention both children were attending a preschool support class and were being seen by therapists from the Spastic Centre of NSW.

Tahlia:

Tahlia has cerebral palsy with spastic quadriplegia, her left side being more affected than her right. She was first seen regularly for occupational therapy at the age of two and from the age of three was involved in a preschool early intervention program. She was independently mobile in a Kaye Walker, on a trike or by crawling. She had a right hand preference and full active range of movement in her right upper limb. Her sensation, when assessed, was within normal limits. Tahlia was functioning at an academic level slightly below her age and she also had some difficulties with her speech and language.

Upper Limb Status prior to Casting: Tahlia used her left hand as an active assist and stabiliser. She was able to grasp using a radial-digital pattern with her wrist in flexion and full ulnar deviation. She would spontaneously attempt bilateral tasks and was able to manipulate objects bilaterally. She had full passive range of movement in her left upper limb excepting some limitations at the end of her radial deviation and supination ranges. Her active range of movement was limited in all planes at the wrist and forearm, including: no active supination, limited wrist extension and no radial deviation. She did demonstrate some active wrist extension but was unable to use this during occupational

performance.

Tahlia was independent in most self care activities but had some difficulty with buttons, shoes, socks and laces. She was able to eat with a spoon or fork in her right hand only. When crawling she tended to weight bear on an open right hand and fisted left hand. She was able to access a keyboard with her right index finger.

Tahlia was assessed for upper limb casting when she was 4 years and 10 months using the criteria previously outlined. She had fair voluntary control, intact sensation, was a motivated child who would benefit from functional hand improvement and had supportive and realistic parents. The general aims of wrist casting were to increase her active and passive ranges of movement and provide her with enhanced performance of her left upper limb.

Estelle:

Estelle was a five year old girl with spastic quadriplegia cerebral palsy. She was initially seen for occupational therapy at the age of 16 months. Estelle was unable to move independently, other than rolling, but was able to forearm prop or sit cross legged in order to play when on the floor. Independent mobility was aided through the use of a hand operated motorised bike or a right side hand controlled electric wheelchair.

Estelle had a right hand preference and used her left hand as an active assist or stabiliser. Increased muscle tone was evident in her left upper limb when she was engaged in any activity. Her sensation was within normal limits and she presented as a bright, interactive little girl.

Upper Limb status prior to casting: Estelle had limitations in both active and passive upper limb ranges. Her main limitations included: elbow extension, wrist extension, radial deviation and supination. When grasping she tended to hold her wrist in flexion and ulnar deviation, with her left index finger staying in extension. She also displayed some excessive upper limb movements when attempting to grasp (See Figure 1).

She was unable to form a pincer grasp or grasp small objects and used a palmer grasp and release pattern. She had underlying muscle weakness which also affected the quality of her

Figure1: Estelle, grasping pattern used pre casting

grasp. Estelle was dependent in most self care activities but was able to finger feed and help with some aspects of dressing. She accessed a keyboard with her right index finger.

Estelle also fitted the criteria for serial wrist casting and was initially cast at the age of 5. The main aims of her casting program were to increase active and passive ranges of movement,

improve the quality of her grasp and release, develop a pincer grasp and improve overall functional use of her left hand.

Method

Tahlia and Estelle both had a series of plaster wrist casts. Tahlia having three casts over a period of 19 days and Estelle having two casts over 14 days.

Cast number:	Tahlia	Estelle
1	5° wrist flexion 5° ulnar deviation	35° wrist extension 5° ulnar deviation
2	wrist neutral	50° wrist extension 5° radial deviation
3	60° wrist extension 5° radial deviation	 

Table2:Position of the wrist during each cast

Prior to the application of the first cast active and passive upper limb ranges of movement measurements were recorded using a goniometer. Video was then taken of each child performing an identical set of grasp and release exercises with a variety of different sized cubes and pellets as well as completing a set of bilateral tasks that included bead threading and opening a bottle. Video was also taken of each child performing individual activities that related directly to their individual goals. These final activities included drawing, crawling, eating and dressing activities.

Each plaster cast was applied with the wrist placed in a position that still enabled the child to actively extend her fingers (See Table 2 and Figure 2).

This positioning was important as active use of the hand while in the cast is an essential part of the casting programme. The casts were left on for between 5 and 7 days as serial inhibitory casting is most effective over shorter periods as further contractures due to immobilisation can occur if casting time is increased (Chapparo, 1992). Following the removal of one cast, the upper limb was cleaned, the skin checked and necessary ranges of movement noted. Another cast was then applied almost immediately.

Figure2: Position of wrist in the cast to allow finger extension

Additional support was required with all of Tahlias casts due to her crawling. This was provided in the application of additional plaster strips extending the length of the cast on the volar surface. Another option in these circumstances can also be the use of fibreglass casting material.

While wearing their wrist casts both children

were seen twice weekly for occupational therapy. A home therapy program was also followed. The two children were encouraged to use the casted hand for as many activities as possible, including specific activities that targeted finger extension, grasp and release and use of a pincer grasp. Bilateral tasks were also encouraged.

Following the removal of the final casts in both children, a wrist extension orthosis was manufactured. These orthoses supported the wrist in approximately 20 to 30 of wrist extension.

Initially the orthoses were worn for the majority of the school day when the children were involved in their preschool program. The orthoses were not worn during rest periods or at night. Wearing of the orthoses was gradually reduced over a three month period as active strength in the wrist extensors was noted.

RESULTS

The immediate results of both casting programs was an increase in active and passive ranges of movement in the affected upper limb as well as an overall improvement in hand position and hand function (See Tables 3 and 4). The specific

ranges of wrist extension and wrist deviation were measured pre and post casting. Increases in active and passive supination ranges were also noted although these were not specifically targeted.

 	Pre casting	Post casting
Wrist extension with finger extension	Active: 0 Passive: 0 – 50	Active: 0 – 15 Passive: 0 – 90
Wrist extension with finger flexion	Active: 0 – 15 Passive: 0 – 50	Active: 0 – 50 Passive: 0 – 90
Radial Deviation	Active: 0 Passive: 0 – 10	Active: 0 – 5 Passive: 0 – 30

Table3:TAHLIA: Active and Passive Range of Motion Measurements pre andpost wrist casting

Tahlia:Changes in Performance of Occupational Tasks and Routines

Tahlia also made many functional gains, including:

*crawling on open left palm

*ablility to place left forearm flat on table surface

* ability to hold and use a knife and fork together

*ability to stabilise paper for writing more easily

*increases in dressing speed

*grasp and release with active wrist

extension

*improved grasp and release patterns with some active radial deviation

*overall improvement in hand positioning

(See Appendix 1, Figures 3 and 4 for pre and post casting grasp patterns: Tahlia)

 	Pre casting	Post Casting
Wrist extension with finger extension	Active: 0 Passive: 0 – 60	Active: 0 – 10 Passive: 0 – 90
Radial Deviation	Active: 0 Passive: 0 – 15	Active: 0 – 10 Passive: 0 – 20

Table4:ESTELLE: Active and Passive range of motion measurements pre andpost casting

Estelle:Changes in Performance of Occupational Tasks and Routines

Estelle also demonstrated gains in range of movement and function. These included:

*ablity to grasp with wrist in slight extension with neutral to only slight ( 5 ) ulnar deviation

* ablity to pick up small objects using

a pincer or lateral pinch grasp

*ablility to clap and play finger games

*ability to hold a knife and fork in two hands but unable to use them functionally due to weakness

*ablility to stabilise objects more easily

*used her hands spontaneously and appropriately for bilateral tasks

(See Appendix 2, Figures 5 and 6 for examples of pre and post casting grasp patterns : Estelle)

CONCLUSION

Tahlia and Estelle were both preschool aged children with cerebral palsy who were appropriate for serial wrist casting. Both made significant gains in range of movement and in upper limb occupational performance. The gains made in range of movement were maintained for at least three months at which time only slight decreases were noted. These decreases had little impact on the girls functional ability. They were both cast again the following year and further gains in range and function occurred.

REFERENCES

Barnard, P., Dill, H., Eldredge, P., Held, J.M., Judd, D.L.M. &

Nalette, E. (1984). Reduction of hypertonicity in early casting in a comatose head-injured individual. Physical Therapy, 64(10), 1540-1542.

Booth, B.J., Doyle, M. & Montgomery, J. (1983). Serial casting for the management of spasticity in the head-injured adult. PhysicalTherapy, 63(12), 1960-1966.

Chapparo, C.J. (1992). Notes from: Upper limb casting course. The Spastic Centre of NSW, Occupational Therapy Department.

Chapparo, C.J. & Stewart, K.S. (1993). Wrist casting to improve functional control of the wrist and hand in cerebral palsy: A case study. Proceedings of the 6th State Conference of the NSWAOT. Mudgee, NSW, Australia.

Chapparo, C.J. & Ranka, J.L. (1994). Upper limb Orthotics. Course notes, Post graduate certificate in neurology, The University of Sydney, Faculty of Health Sciences, School of Occupational Therapy. PO Box 170, Lidcombe, NSW 2141.

Cherry, D.B. & Weigand, G.M. (1981). Plaster drop-out casts as a dynamic means to reduce muscle contracture: A case report. PhysicalTherapy, 61(11), 1601-1603.

Copley, J., Watson-Will, A. & Dent, K. (1996). Upper limb casting for clients with cerebral palsy: A clinical report. The AustralianOccupational Therapy Journal, 43, 39-50.

Cruickshank, D.A. & OÌ“Neill, D.L. (1990). Upper extremity

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DeMatteo, C. (1991). Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy. Developmental Medicineand Child Neurology, 33, 379-387.

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Unpublished manuscript. (Available from, The Spastic Centre, Ryde, NSW).

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APPENDIX1: Pre and post casting grasp patterns: Tahlia

Figure3:Pre cast grasping

Figure4:Post cast grasping

APPENDIX2: Pre and Post cast grasp patterns: Estelle

Figure5: Pre cast grasping

Figure6: Post cast grasping