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The Effects of Serial Casting Duration on Ankle ROM and Mobility in Ambulatory Children with Spastic… Banda, Alison; Deglau, Jessica; Okrainetz, Scott; Schwab, Klara 2011-08

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The Effects of Serial Casting Duration on Ankle ROM and Mobility in Ambulatory Children with Spastic Cerebral Palsy  Systematic Review Final Report  RSPT 572 Supervisor: Kathy Davidson  Alison Banda, Jessica Deglau, Scott Okrainetz & Klara Schwab  Cerebral Palsy ? A non-progressive disorder caused by brain lesions prenatally, perinatally or postnatally (0-2 yrs)  ? Most common cause of neuromuscular disability in children  ? Cerebral Palsy (CP) is classified as spastic, ataxic or dyskinetic  (18) Cerebral Palsy ? Spastic Cerebral Palsy: ? Most prevalent (77%) ? Hypertonia  ? ? interdigitation of actin and myosin ? Development of contractures ? Immobility around the joint ? muscle atrophy, connective tissue weakness, and ? resistance to stretch ? Development of an equinus gait ? Dynamic non-fixed equinus ? Fixed equinus  (1, 2)    Treatment Options Treatments for the prevention and management of contractures include:  ? Invasive ? Surgery (eg. Tendon lengthening) ? Botulinum Toxin A  ? Non-Invasive ? Manual Short Duration Stretching ? Prolonged Stretching Methods ? Serial casting ? AFOs  ? Splinting (4, 5) Surgical Intervention ? Surgical tendon release is a common method used to treat spastic muscles  ? Best if performed after 6 years of age ? 50% reoccurrence if surgery under 3 years of age  ? Risks of surgery: ? Over-lengthening ? Infection ? Scarring ? Side-effects of anaesthesia (6) Botulinum Toxin A ? Injections are fast and have few side-effects ? Reported benefits: ? Increased ROM ? Decreased Spasticity ? Improved Function ? Not always available outside of urban areas ? Expensive especially if no insurance ? Require specialist appointments ? ? Wait times  (5) Manual Short Duration Stretching ? Non-pathological muscle usually held >20sec ? Spastic muscles, no long-lasting clinical benefits in: ? ROM,  Mobility,  Contracture risk,  Decreased spasticity   ? Still has place as adjunct to other therapy for: ? Muscle cramps ? Joint lubrication ? Changing position  ? Fitting devices (7, 8) Serial Casting Guidelines ? Research shows >6hr required to prevent contracture development  ? Casting is a good way to achieve long-term stretch: ? No specific guidelines for serial casting for this clinical population ? In general, clinically recommended 1-4 progressions of 7-10 days ? Supplement casting with: ? Physiotherapy ? Heel-cord lengthening ? Balance training ? Night splint & AFO usage. (12, 13) Research Question ? To determine  if serial casting has an effect on passive dorsiflexion range of motion (PROM) in children with spastic CP. Primary Aim ? To determine if serial casting  has an effect on spasticity, gait, and functional mobility in children with spastic CP. Secondary Aim ? To explore whether the different intensities and durations of casting impact the effect of casting and its sustainability.   Secondary Aim  What is the most effective prolonged stretch intervention duration to treat children with spastic Cerebral Palsy?  PICO: P  Ambulatory children with spastic cerebral palsy ? Level I-III on GMFCS ? 0-18 years old I  Serial casting with or without follow-up treatment C  The effect of different serial casting parameters on outcomes O  Dorsiflexion PROM, spasticity, gait characteristics, and function Search Strategy ? 4 search streams were combined to address the research question:  ? Children with Spastic Cerebral Palsy ? (cerebral palsy)  ? (spastic* OR tone OR hyperton* OR contracture)  ? The Ankle Joint ? (ankle OR dorsiflex* OR soleus OR gastroc* OR triceps surae OR equinus OR toe-walk OR lower extremity)  ? Serial Casting Interventions ? (serial cast* OR prolong* OR sustain* OR long duration OR stretch* OR passive)    Search Strategy ? Inclusion/Exclusion Search Strategy ? Inclusion/Exclusion Inclusion Criteria  ? All study types ? RCT, individual cohort, case-control/series, before-and-after  ? All study publication dates (no limits)  ? Studies involving children with spastic CP: ? 0-18 years old ? Level I-III on GMFCS  (?Ambulatory?)  ? Limited dorsiflexion ROM and/or equinus walking ? Studies must include ROM as an outcome measure  ? Studies examining effect of serial casting on ankle ROM, walking abilities, and/or functional activities  ? Studies with participants undergoing concurrent treatments can still be included as long as this alternative treatment is not the focus of the study. Exclusion Criteria ? Studies not investigating the ankle joint  ? Non-English studies  ? Studies involving non-human participants  ? Studies focusing on effects of recent surgeries, recent Botox treatment, or concurrent alternative treatments  ? Studies scoring ?5? on the AACPDM level of evidence scale  ? Studies scoring less than 16/32 on the Downs and Black Quality Assessment Scale (19, 20) Quality Assessment:   (1) Methodological Assessment Downs & Black Checklist (1998):  ? Based on 5 aspects of quality  1) Reporting  2) External validity  3) Internal validity (selection bias             and blinding)  4) Confounding  5) Power  ? Can be used for RCT and non-RCT  ? Good inter-rater reliability            External Valididty yes=1,no=0, unable to determine=0 Score ? 11. Were the subjects asked to participate in the study representative of the entire population from which they were recruited?       12. Were those subjects who were prepared to participate representative       13. Were the staff, places, and facilities where the patients were treated, representative f the treatment the majority of pt's receive?               Internal validity -bias yes=1,no=0, unable to determine=0 Score ? 14. Was an attempt made to blind study subjects to intervention they have received?       15. Was an attempt made to blind those measuring the main outcomes of the intervention?       (19, 20) Quality Assessment:  (2) Levels of Evidence AACPDM Levels of  evidence (1999):   ? Based on Oxford scale  ? Adapted for CP and developmental disability research  ? Developed for heterogeneous populations and   ? incidence  ? Can be used for single study design (19, 20) Data Extraction ? Standardized forms completed independently by 2 reviewers:  ? (1) Study Characteristics ? Title, author, year, quality assessment score, level of evidence, study setting, and recruitment strategies ? (2) Traits of Participant ? Age, GMFCS level, number of participants / drop-outs ? (3) Serial Casting Parameters  ? Details on intensity of stretching, total treatment time, number of castings ? (4) Study outcomes  ? Primary outcome: DF ROM ? Secondary outcomes (?others?): Spasticity, gait, function  ? Any disagreements were arbitrated by an impartial 3rd team member  Data Extraction - Example INTERVENTION:   Manual / Short Duration Stretch Prolonged / Device-Assisted Stretch Alternative Method DF Stretch Type   Method   Serial Casts (short-leg fiberglass walking cast)     Hold time       Frequency       hrs/day   24 hrs/day   Intensity   Mid-way between R1&R2 Length of Intervention   3-6 wks (3 x 1-2 wks progressions) OUTCOME:   Group #1 Group #2 Comments Specify: CP Specify: ITW (1) ROM   Method of        Measure Rotating foot plate Rotating foot plate * Are these changes in ROM significant at 6 wks post-Tx?   Pre-Tx 4.6 deg of DF (SD 1.7) 3.5 deg of plantarflex (SD 2.6)   Post-Tx 16.5 deg of DF (SD 1.4) 9.5 deg of DF (SD 1.4)   Change Increased DF ROM Increased DF ROM   p value p<0.001 p<0.001   f/u results f/u at 6 wks:                                     10.7 deg of DF (SD 1.9) f/u at 6 wks:                                                  11.6 deg of DF (SD 2.1) Bouwer, B., Davidson, L.K., & Olney, S.J. (2000). Serial casting in idiopathic toe-walkers and children with spastic cerebral palsy. Journal of Pediatric Orthopaedics, 20(2), 221-225.  Study Characteristics ? 11 papers included in the SR  ? Study designs: ? RCT, outcome research (before & after), retrospective research ? AACPDM levels of evidence 1, 2, & 4 ? Downs & Black scores: 21-28/32  ? Published between 1986 & 2006  ? Subject information: ? n = 7-28  ? Mean ages: 2.58 years to 9.40 years ? Mostly 4 years to 7 years Study Characteristics ? Casting procedures: ? Cast types: ? Lightweight & fibre-glass; below knee & short-leg walking casts ? Intensity of stretch: ? Neutral DF, 0-5? or 0-10? DF, midway between R1 and R2, and to max DF ? Duration of casting: ? Totals: 2.8 weeks ? 6 weeks ? Casts changed every 1-3 weeks  ? Additional treatments: ? 6 studies used stretching devices post-casting ? AFOs, night splints/plasters, bi-valved fibre-glass splints ROM - Results Study O weeks Follow-Ups Changes Significant? Changes Significant? Ackman et al. (2005) p ? 0.03* 3 & 6 w p = 0.03* 5 m ns Booth et al.  (2003) 5.54? (? 3.87) per week Brouwer et al. (2000) 11.9? p < 0.01* 6 w 6.1? Brouwer et al.(1998) 12.3? p < 0.01* 6 w 6.8? p < 0.05* Corry et al. (1998) 2 w KE: 5? & KF: 0? KE: p = 0.047*  KF: p = 0.02* 12 w KE: 0? & KF: 5? ns Cottalorda et al. (2000) KE: 17? & KF:16?  3y 1m  KE: 6? & KF: 6? ROM - Results Study O weeks Follow-Ups Changes Significant? Changes Significant? Flett et al. (1999) 1 month 7.70? p < 0.001* (ANOVA across time ) 3 month 8.00? 5 month 8.87? Glanzman et al.(2004) 15.0? (? 4.5) Kay et al. (2004) 3 months 17.6? p = 0.0005* 6 & 12 months p-value not provided McNee et al.  (2006) 5 weeks KE: p = 0.02* KF: p < 0.01* 12 weeks KE: ns KF: p = 0.01* Watt et al. (1986) Right: ? 8.8? Left: ?10.3? p < 0.005* (bilateral) 2 weeks Right: ? 9.4? Left: ?9.5? p < 0.005*  5 weeks Right: ? 3.6? Left: ?2.6? ns  ROM ? Results ? All eleven studies showed short term increase in DF ROM post casting  ? General Trends: ? Range: 7.55? to 16? ? Most numbers between 10? and 13?  ? Largest mean change (15-17?)- casted at maximal DF ? Most common protocol:  3-4 week casting, casts changed every 1-2 weeks   ROM ? Discussion ? Large variation in methodology  ? 8 completed follow-up assessments ? 5/8 Significant maintenance of ROM at follow-up ? ROM gains lasted between12 weeks & 6 months  ? 6 used a stretching device post-casting  ? 4/6 Significant maintenance of ROM at follow-up ? May influence long-term maintenance of ROM  ? Unclear if any one casting protocol is superior (3, 5, 9, 10, 14 - 17) Spasticity - Results Study Measure RESULTS 0 weeks Follow-Ups Ackman et al. (2005) MAS & Tardieu p ? 0.02* 3 weeks p < 0.02* 6 weeks p < 0.02* 5 months p < 0.02* Brouwer et al. (2000) Resistance to Passive Stretch p < 0.005* 6 weeks Brouwer et al. (1998) Resistance to Passive Stretch p < 0.01* 6 weeks p < 0.05* Corry et al. (1998) Ashworth Scale 2 weeks ns 12 weeks ns Flett et al. (1999) MAS 1-3-5 months p < 0.001* (ANOVA across time) Kay et al. (2004) MAS 3 months p = 0.0031* 6 & 12m Significant  (no p-values) Spasticity - Results ? 5/6 studies showed significant reduction in spasticity post-casting ? Brouwer et al.(1998): 0 & 6 weeks ? Brouwer et al.(2000): 0 weeks ? Ackman et al.(2005): Up to 5 months ? Flett et al.(1999): Up to 6 months ? Kay et al.(2004): Up to 12 months ? Corry et al.(1998): No significant changes at 2 weeks & 12 weeks  Use of AFOs, night splints, and/or PT post-casting (5, 10, 11, 15, 17, 21) Spasticity - Discussion ? No major differences in casting parameters between studies: ? 3-6 weeks of total casting ? Casted at 0-10? DF ? Level I-III GMFSC ? Why didn?t Corry et al. (1998) find significance?  ? Differences in mean ages? ? 5 studies with ?significance?: 3y 6m to 9y 4m ? Corry et al.(1998): 4y 7m ? Casting more effective in slightly older age group? ? Overlap in mean ages & limited number of studies, therefore difficult to draw conclusions   (10) Spasticity - Discussion ? Does the use of night splints,  AFOs, and/or PT assist in the maintenance of improvements?  ? The three studies which used stretching devices post-casting had the longest lasting effects (5-12 months) ? Consistent with Tardieu et al. in1988  ? The two significant studies which did not use stretching devices did not have follow-up beyond 6 weeks ? Unknown if improvements maintained without their use (12) Temporospatial - Results Study Measure Outcome RESULTS 0 weeks Follow-Ups Ackman et al. (2005) Vicon Motion System Stride Length ns 3w, 6w, 5m ns Velocity ns 3w, 6w, 5m ns Brouwer et al. (2000) Sagittal Barefoot Walking Stride Length ns 6 weeks ? Velocity ns 6 weeks ns McNee et al. (2006) 3-D Vicon Motion Capture System Stride Length ns 12 weeks ns Velocity ns 12 weeks ns Cadence ns 12 weeks ns % Single Support p = 0.05* 12 weeks ns Temporospatial ?  Results & Discussion ? Three studies used video gait analysis to look for improvements in stride length and velocity during gait ? Two studies followed up with AFOs; one study did not mention AFO use post treatment ? None of these studies found significant improvements immediately post-casting, or at any follow-up assessment for any temporospatial measure   (3,11, 15) Ankle Kinematics - Results Study Measure Outcome RESULTS 0 weeks Follow-Ups Ackman et al. (2005) Vicon motion System DF at initial contact p ? 0.007* 3w, 6w, 5m p ? 0.007* Max DF in stance p ? 0.01* 3w, 6w, 5m p ? 0.01* DF in swing p ? 0.02* 3w, 6w p ? 0.02* 5m ns Corry et al. (1998) 3-D Vicon motion capture system DF at initial contact 2 weeks p = 0.02* 12 weeks ns Max DF in stance 2 weeks p = 0.01* 12 weeks ns Kay et al. (2004) 3-D Vicon motion capture system Max DF in stance 3 months p = 0.0004* 6m, 12m Significant (no p-value) DF in swing 3 months p = 0.004* 6m, 12m Significant (no p-value) McNee et al. (2006) 3-D Vicon motion capture system Max DF in stance p = 0.01* 12 weeks ns Ankle Kinematics ? Results ? 4 studies used video gait analysis to monitor changes in ankle kinematics, including: ? Dorsiflexion at initial foot contact ? Peak dorsiflexion in stance and in swing ? Overall maximum dorsiflexion during gait  ? All 4 studies found significant improvements in ankle kinematics ? 2 remained significant at 12 weeks (Ackman; Kay) ? 2 no longer significant at 12 weeks (Corry; McNee)   (3,  10, 11, 17) Ankle Kinematics ? Discussion Do improvements from serial casting translate  to improved dynamic ROM?  ? 2 studies maintained significant improvements   ? Subjects wore night splits or AFOs post-casting (Ackman; Kay) ? Splinting may have influenced maintenance of improvements  ? 2 studies improvements were NOT significant at 12 weeks ? Corry et al. (1998) did not allow splint use post-casting ? McNee et al. (2006) 6 of 9 subjects wore AFOs post-casting  ? Conflicting evidence ? cannot draw conclusions  ? General trend towards improvement in dynamic ROM (3, 10, 11, 17) Qualitative Measures of Gait - Results Study Outcome Measure RESULTS 0 weeks Follow-Ups Brouwer et al. (2000) ?Toe-Walking? Sagittal barefoot walking 8/8 plantigrade  (no p-value) 6 weeks 2/8 reverted back to digitgrade (no p-value) Corry et al. (1998) Gait improvements PRS scale 2 weeks p = 0.016* 12 weeks ns Rated ?change? 2 weeks p = 0.039* 12 weeks p = 0.031* PRS total score 2 weeks p = 0.016* 12 weeks p = 0.031* Cottalorda et al. (2000) ?Toe-Walking? Observation 30/30 feet: ? heel-toe or flat foot gait Flett et al. (1999) Global Score Scale (GSS) 2-D video gait analysis 1-3-5 months ns (ANOVA across time) Physician Rating Scale (PRS) 2-D video gait analysis 1-3-5 months p < 0.001* (ANOVA across time) Watt et al. (1986) ?foot-floor? contact during gait Video observation p < 0.05* (bilateral) 2 weeks p < 0.05 (bilateral) 5 months Right foot: p < 0.05 Left foot: ns Qualitative Measures of Gait ? Results Five studies investigated the effect of serial casting on  qualitative gait changes; all showed short term  improvements  ? Observation of barefoot standing and walking ? Brouwer et al. (2000):  All subjects displayed improved gait patterns post-casting ? Not stated if improvements sustained at 6 weeks, however 2 subjects returned to equinus gait  ? Cottalorda, et al. (2000):   All subjects showed improved function in heel-toe gait ? 2/3 improvements remained significant at 18 months  ? Watt, et al. (1986):  Significant improvement in foot contact in stance ? More subjects displayed improved right foot contact at 5 months post than left foot contact ? Authors were unable to explain the difference between right and left sides    (14-16) Qualitative Measures of Gait ? Results ? Video gait analysis rated by the Physicians Rating Scale (PRS) ? Corry, et al. (1998) ? Significant improvement in PRS rating for foot contact at 2 weeks; not significant at 12 weeks. ? Significant change in overall PRS rating for crouch, knee, and foot contact at 2 weeks, remained significant at 12 weeks ? Flett, et al. (1999)  ? Significant improvement in PRS rating for crouch and foot contact over time (2, 4, 6 months post-casting).  (5, 10) Qualitative Measures of Gait ? Discussion ? Conflicting evidence for the effectiveness of serial casting on qualitative gait changes ? Difficult to compare and draw conclusions  ? It appears that serial casting can be effective at improving the quality of gait in children with CP  ? Longevity of improvements unclear ? It can be inferred that serial casting appears effective for improving gait when short-term splinting is used post-casting  (5, 14, 16) Function - Results Study Outcome Measure RESULTS 0 weeks Follow-Ups Cottalorda et al. (2000) Parental satisfaction Rated ?improvement? by parents 18/20: ?significant? 2/20: ?moderate? Flett et al.  (1999) Gross Motor Functional Measure (GMFM) GMFM: Standing & Dynamic subscales 1-3-5 months Standing:  p < 0.04* Dynamic:  p < 0.01* Functional improvement Parental report 1-3-5 months 2/20: ?general improvements? Glanzman et al. (2004) Parental Satisfaction Parental report 6/6 satisfied with results Functional Improvement Clinician evaluation 6/6 showed improvements Kay et al.  (2004) Gross Motor Functional Measure (GMFM) GMFM percent score 3 m ns 6 & 12 m Significant ? from baseline (no p-value) Watt et al. (1986) Develop-mental motor skills  Assessment & inventory  of motor skills 2 weeks ns 5 m ns Function - Results ? 4/5 studies showed some kind of functional improvement post-casting  ? Parental Reports: ? Cottalorda et al. ((2000): 18/20 significant & 2/10 moderate ?improvements? ? Glanzman et al. (2004): 6/6 satisfied with results  ? Clinician Report: ? Glanzman et al. (2004): 6/6 improvements in function (mostly parameters in gait)  ? GMFM: ? Flett et al. (1999): ? 1, 3, 5 months ? Kay et al. (2004): ? 6, 9, 12 months, ? 3 months  ? Watt et al. (1986): No significant improvements in Developmental Motor Skills Tool at 2 weeks or 5 weeks ? Flett et al. (1999): only 2/10 ?general improvements? (parental report)  (4, 5, 14, 17) Function - Discussion GMFM:   ? Two studies found improvements, but at different times: ? Flett: significant at 1, 3, 5 m ? Kay: significant at 6, 9, 12 m, but not at 3 m ? Both casted at neutral DF and used stretching devices post-casting  ? Why different? ? Differences in age? ? Flett: 3.56 years Kay: 7.1 years ? Differences in casting procedures? ? Flett: 4 weeks Kay: 6 weeks ? Possible that changes observed due to normal developmental processes rather than casting procedures ? Further research is needed (only 2 studies!)  (5, 17) Function - Discussion ? In general, most studies found improvements despite differences in casting parameters ? 2.8 to 6 weeks of total casting ? Casted at 0-10? DF ? Max DF  ? No major differences in interventions between studies which reported improvements and those that did not  ? Difficult to compare studies because many outcome measures   Conclusion:  Summary of Evidence Results from this SR indicate that:  1. Serial casting can be an effective non-invasive treatment option for improving dorsiflexion ROM and reducing spasticity in children with spastic CP.  2. These improvements may have some carry-over effect on gait quality and functional mobility. ? Conflicting evidence of impact on ankle kinematics ? No effect evident on stride length and velocity   Conclusion: Summary of Evidence 3. No specific casting parameters have been identified: ? In the majority of studies, casting for 3-6 weeks was found to be effective ? Casts were changed weekly or biweekly  ? No indication of the ?best? intensity of stretch  4. The use of AFOs and/or night splints post-casting may assist in the maintenance of improvements in ROM, spasticity, and gait quality. ? This is consistent with Tardieu et al. in1988 Limitations ? Several factors made the comparison between studies difficult to execute:  1. Differences in methodology: ? Casting parameters (duration & intensity) ? Post-casting treatments   ? Poor control of post-casting treatments in some studies (e.g. 6/9 participants wearing AFOs). ? Follow-up times (0 weeks ? 3 years)  2. Differences in outcome measures ? E.g. Different measures for ?function?   3. Differences in data reported ? E.g. ROM data presented as change in ROM with Standard Deviation and/or as p-values   Limitations ? The study of a clinical population also presents challenges:  1. Large variability between participants ? Differences between Level I & III, and within a single level   2. Small sample sizes  3. Lower levels of evidence ? Well controlled rigorous studies are difficult to execute ? Unethical to deny treatment in order to create a control group ? Difficult to control for external influences ? Note: this SR included several studies with an AACPDM level 4 evidence   Clinical Implications ? The findings in this SR are consistent with the general guidelines for serial casting:  ? 1-4 progressions of 7-10 days ? ? 3-6 weeks in total, with weekly to bi-weekly progressions  ? Follow-up casting with PT, stretching, strengthening, and night splints ?  ? The results from this SR indicate that the use of AFOs and night splints may prolong the results of casting.   ? Follow-up stretching devices are an important part of post-casting protocol. Clinical Implications:  a few new considerations ? Duration of stretch ? Wide variety of total treatment times can be effective ? Use clinical reasoning to determine the best number of progressions for each client. ? Aim: To maximize the benefits & minimize any detrimental effects of prolonged immobilization. ? ?More is not always better?  ? Intensity of stretch ? Although casting in maximal dorsiflexion may result in larger gains at 0 weeks, there is no evidence that these improvements will be sustained. ? It is important to consider client comfort ? Casting at 0-10 degrees DF and at midway between R1 and R2 have also been shown to be effective.  ? ?More may not be better?   Clinical Implications:  one more consideration  ? Adjunct treatments: ? Do not discontinue other adjunct treatments ? Continue with strengthening, stretching, and balance training as recommended for the client ? Although ROM exercises may not result in improved ROM or spasticity for this population, they still have a place as an adjunct treatment ? Joint lubrication, position changes, and prevention of muscle cramping, especially in non-ambulatory children References ? 1) Kruse M, Michelsen SI, Flachs EM, Br?nnum-Hansen H, Madsen M, Uldall, P. Lifetime costs of cerebral palsy. Dev Med Child Neurol. 2009 Aug; 51(8): 622-628. ? 2) Farmer SE, James M. Contractures in orthopaedic and neurological conditions: A review of causes and treatment. Disabil Rehabil. 2001 Sep; 23(13): 549-558.  ? 3) McNee AE, Will E, Lin JP, et al. The effect of serial casting on gait in children with cerebral palsy: preliminary results from a crossover trial. Gait Posture. 2006 Mar; 25(3): 463-468. ? 4) Glanzman A, Kim H, Swaminathan K, Beck T. Efficacy of botulinum toxin A, serial casting, and combined treatment for spastic equinus: A retrospective analysis. Dev Med Child Neurol. 2004 Dec; 46(12): 807-811. ? 5) Flett PJ, Stern LM, Waddy H, Connell TM, Seeger JD, Gibson SK. Botulinum toxin A versus fixed cast stretching for dynamic calf tightness in cerebral palsy. J Paediatr Child Health. 1999 Feb; 35(1): 71-77. ? 6) Ratey TE, Leahey L, Hyndman J, Brown DCS. Recurrence after Achilles lengthening in cerebral palsy. J Pediatr Orthop. 1993 Mar-Apr; 13(2): 184-187. ? 7) Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr, K. Stretch for the treatment and prevention of contractures (Review). Cochrane Database Syst Rev. 2010 Sep; 8(9): 1-26. ? 8) Pin T, Dyke P, Chan M. The effectiveness of passive stretching in children with cerebral palsy. Dev Med Child Neurol. 2006 Oct; 48(10): 855-62.   ? 9) Booth MY, Yates CC, Edgar TS, Bandy WD. Serial casting vs. combined intervention with botulinum toxin A and serial casting in the treatment of spastic equinus in children. Pediatr Phys. 2003 Winter; 15(4): 216-20. ? 10) Corry IS, Cosgrove AP, Duffy CM, McNeil S, Taylor TC, Graham HK. Botulinum toxin A compared with stretching casts in the treatment of spastic equinus: A randomised prospective trial. J Ped Orthop. 1998 May-Jun; 18(3): 304-311. ? 11) Ackman J, Russman B, Thomas S, et al. (2005). Comparing botulinum A with casting for treatment of dynamic equinus in children with spastic cerebral palsy.  Dev Med Child Neurol. 2005 Sept; 47: 620-627. ? 12) Tardieu C, Lespargot A, Tabary C, Bret MD. For how long must the soleus muscle be stretched each day to prevent contracture? Dev Med Child Neurol. 1988 Feb; 30(1): 3-10. ? 13) Evidence-based care guidelines for the management of serial casting in children: Serial casting of the lower extremity [Internet]. Cinncinnati: Cincinnati Children?s Hospital Medical Center; 2009 Jan [updated 2009 Aug; cited 2009]. Available from: http://www.cincinnati childrens.org /assets/0/78/1067/2709/2777/2793/9199/317d7f8d-943e-42a0-8a65-0bb0c35addb6.pdf. ? 14) Cottalorda J, Gautheron V, Metton G, Charmet E, Chavrier Y. Toe-walking in children younger than six years with cerebral palsy. The contribution of serial corrective casts. J Bone Joint Surg Br. 2000 May; 82(4):541-544. ? 15) Brouwer B, Davidson LK, Olney, SJ. Serial casting in idiopathic toe-walkers and children with spastic cerebral palsy. J Pediatr Orthop. 2000 Mar-Apr; 20(2): 221-225. ? 16) Watt J, Sims D, Harckham F, Schmidt L, McMillan A, Hamilton J. A prospective study of inhibitive casting as an adjunct to physiotherapy for cerebral-palsied children. Dev Med Child Neurol. 1986 Aug; 28(4): 480-488.    References References ? 17) Kay RM, Rethlefsen SA, Fern-Buneo A, Wren TAL, Skaggs DL. Botulinum toxin as an adjunct to serial casting treatment in children with cerebral palsy. 2004 Nov; 86-A(11): 2377-2384.  ? 18) Odding, E., Roebroeck, M. E., & Stam, H. J. (2006). The epidemiology of cerebral palsy: Incidence, impairments and risk factors. Disability & Rehabilitation, 28(4), 183-191.  ? 19) Butler C. AACPDM methodology for developing evidence tables and reviewing treatment outcome research [Internet]. Milwaukee: American Academy for Cerebral Palsy and Developmental Medicine; 1999 [updated 2003 Jan; cited date unknown]. Available from http://www.aacpdm.org/resources/BUT_guide.pdf.  ? 20) Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions. J Epidemiol Community Health. 1998 Jun; 52(6): 377-384.  ? 21) Brouwer B, Wheeldon RK, Stradiotto-Parker N, Allum J. Reflex excitability and isometric force production in cerebral palsy: The effect of serial casting. Dev Med Child Neurol. 1998 Mar; 40(3): 168-175 Any Questions? 

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