Milne N1, Beattie E1, Miao M1
1Bond University - Institute of Health and Sport, Physiotherapy Department, Faculty of Health Sciences and Medicine, Gold Coast, Australia
Background: Serial casting of the lower limb is commonly used as a therapeutic intervention in paediatric clinical practice with minimal evidence or clinical guidelines to support its efficacy. Evidence-based and best practice methods of serial casting to enhance functional outcomes for children with Cerebral Palsy (CP) remain unclear.
Purpose: This systematic review aimed to determine; i) the effects of serial casting in isolation or in combination with other therapies (with or without pharmacological interventions) for the management of lower limb dysfunction in children with CP and; ii) the longitudinal effects of serial casting at different points in time, post final cast removal.
Methods: A systematic review with meta-analysis was undertaken in November 2017. A literature search was conducted across eight databases (PUBMED, EMBASE, CINAHL, PEDro, OTSeeker, Cochrane, Scopus and Proquest) using the key terms ´Cerebral Palsy´ and ´serial casting´ or synonyms for these terms. Studies were screened, and data were extracted from articles that met selection criteria before critically appraising studies using the Downs and Black critical appraisal checklist. Effects of serial casting on lower limb function were synthesised using findings from fair to good quality studies only. When sufficient evidence existed, relevant to functional outcomes, key findings were extracted, and meta-analysis was undertaken.
Results: From 3084 possible citations identified, 24 articles remained eligible for inclusion. Serial casting of the lower limb was found to be effective for improving ankle dorsiflexion (DF) passive range of motion (PROM), standardised gait assessment measures, modified Ashworth scale (MAS) scores, modified Tardieu scale (MTS) angle, and gross motor function (GMFM). For most measures, desirable effects were observed to be stronger immediately after casting and decreased over time (up to 6 months). Few studies reported outcomes at 12 months or beyond. Serial casting with pharmacological intervention was found to be significantly more effective for improving ankle DF PROM than serial casting alone (MD -3.19 degrees; 95% CI -5.76 to -0.62; P = 0.01; I2 = 0%), however the clinical importance of an additional three degrees is unclear. Several methodological limitations relating to internal validity, inadequate blinding and adjustment for confounding variables were apparent.
Conclusion(s): Serial casting alone is effective in the management of spasticity and soft-tissue contracture in children with CP and was shown to improve several outcomes relevant to lower limb function. Further research using stronger methodological study designs, is indicated to explore long-term effects of serial casting on functional lower limb outcomes in children with CP. Further systematic reviews on this topic would be enhanced by clear reporting of the type of CP and the Gross Motor Function Classification of participants, and the clinical methods of serial casting used, to assist with determining evidence-based methods.
Implications: The findings of this systematic review support the clinical use of lower limb serial castings for improving functional outcomes in children with CP and suggest that the effects may be slightly enhanced when coupled with pharmacological interventions. Clinicians can use this information when developing individualised treatment plans for children who have CP during shared decision-making consultations.
Keywords: Cerebral Palsy, Serial casting, lower-limb
Funding acknowledgements: No funding was obtained to support this research.
Purpose: This systematic review aimed to determine; i) the effects of serial casting in isolation or in combination with other therapies (with or without pharmacological interventions) for the management of lower limb dysfunction in children with CP and; ii) the longitudinal effects of serial casting at different points in time, post final cast removal.
Methods: A systematic review with meta-analysis was undertaken in November 2017. A literature search was conducted across eight databases (PUBMED, EMBASE, CINAHL, PEDro, OTSeeker, Cochrane, Scopus and Proquest) using the key terms ´Cerebral Palsy´ and ´serial casting´ or synonyms for these terms. Studies were screened, and data were extracted from articles that met selection criteria before critically appraising studies using the Downs and Black critical appraisal checklist. Effects of serial casting on lower limb function were synthesised using findings from fair to good quality studies only. When sufficient evidence existed, relevant to functional outcomes, key findings were extracted, and meta-analysis was undertaken.
Results: From 3084 possible citations identified, 24 articles remained eligible for inclusion. Serial casting of the lower limb was found to be effective for improving ankle dorsiflexion (DF) passive range of motion (PROM), standardised gait assessment measures, modified Ashworth scale (MAS) scores, modified Tardieu scale (MTS) angle, and gross motor function (GMFM). For most measures, desirable effects were observed to be stronger immediately after casting and decreased over time (up to 6 months). Few studies reported outcomes at 12 months or beyond. Serial casting with pharmacological intervention was found to be significantly more effective for improving ankle DF PROM than serial casting alone (MD -3.19 degrees; 95% CI -5.76 to -0.62; P = 0.01; I2 = 0%), however the clinical importance of an additional three degrees is unclear. Several methodological limitations relating to internal validity, inadequate blinding and adjustment for confounding variables were apparent.
Conclusion(s): Serial casting alone is effective in the management of spasticity and soft-tissue contracture in children with CP and was shown to improve several outcomes relevant to lower limb function. Further research using stronger methodological study designs, is indicated to explore long-term effects of serial casting on functional lower limb outcomes in children with CP. Further systematic reviews on this topic would be enhanced by clear reporting of the type of CP and the Gross Motor Function Classification of participants, and the clinical methods of serial casting used, to assist with determining evidence-based methods.
Implications: The findings of this systematic review support the clinical use of lower limb serial castings for improving functional outcomes in children with CP and suggest that the effects may be slightly enhanced when coupled with pharmacological interventions. Clinicians can use this information when developing individualised treatment plans for children who have CP during shared decision-making consultations.
Keywords: Cerebral Palsy, Serial casting, lower-limb
Funding acknowledgements: No funding was obtained to support this research.
Topic: Paediatrics
Ethics approval required: No
Institution: Bond University
Ethics committee: Bond University Human Research Ethics Committee
Reason not required: It is a systematic review of previously published research.
All authors, affiliations and abstracts have been published as submitted.
