Orthotics/Prosthetics

Kevin Matthews, CO/LO, Advanced Orthopedic Designs, attended a lecture at the 2011 American Orthotic and Prosthetic National Assembly by Beverly Cusick, PT, MS, COF, Progressive Gaitways, and was intrigued by what he heard. Cusick and three orthotists sat on a panel discussing a new paradigm shift in equinus deformity management. The approach, setting ankles in plantar flexion (PF) to reduce PF contracture, was all but labeled taboo in the field of orthotics, according to Matthews. Still, after listening to Cusick and the panel, Matthews was convinced he could incorporate the unusual technique into his practice.

	Beverly Cusick

The revised approach

In April 2011, O&P Business News published Cusick’s article, Help Patients Manage Equinus Deformity. Cusick, an associate professor for Rocky Mountain University’s Program in Pediatric Physical Therapy, wrote that the new approach was “exemplified in the principles and methods employed in the specialized design of below-knee serial casts used for postural and gait training and in the ‘tuning’ of solid AFOs and foot wear combinations.”

The new paradigm is an application of serial casting principles and strategies using orthoses. Stretching the calf muscles is not the objective; rather, the focus is on using them more effectively. According to Cusick, lifting the heel allows for the calf muscle to relax and adapt to its new use. By posting under the elevated heel, the foot joints can be protected from pronating and the calf muscle is off tension. The flat floor under the forefoot and the shaft of the cast help to bring the body weight back onto the heel where it belongs. This relieves the calf muscle of constant work to maintain upright position, and allows it to adapt to a new, more normal use history.

	Freeman Miller

“We have to get the heel weight bearing with these kids,” Matthews told O&P Business News. “Because of the way that they walk, their weight is always forward on the forefeet, and even appear to be only pronating. They never get normal heel loading.”

“If you look at their AFOs, there is often a big pile of lint where their heel pad should be. They are constantly pushing with their plantar flexors to keep them upright,” Cusick added. “With body weight carried forward on the foot, the ankle plantar flexors activate, along with most other muscles of the lower limb, to keep them from falling forward. This constant activation to stay upright shortens the muscles over time, changing a “dynamic” equinus to a “fixed” equinus deformity. The issue is one of the need for postural control that prevails over the ability to use the limbs for walking.”

“Normally, the child’s AFOs are set at 90°, so if they tried to rest on their heels, the shortened calf muscles would require them to fall over backward. Most pronate the foot inside the AFO instead.” Matthews said. “But if we fill the gap between their elevated heels and the ground, they can learn to relax in the standing position and put weight through their heels. I believe with the muscle being relaxed, over time it will elongate and become a more efficient muscle.”

Disagreement

Freeman Miller, MD, medical director, duPont Hospital for Children, read the Cusick article and acknowledged that the goal for specialists — pediatric orthopedists and orthotists — is to get the patient in a position where they are stable and comfortable. To that end, both sides are in complete agreement. From there, however, the roads to effective management of equinus deformity split.

“I think the problem with this approach is that it is sort of a fad that periodically sweeps through, in my perspective,” Miller said. “I would strongly disagree with the concept that no matter how much equinus, you just keep building it up. Equinus is a disabling condition as you move towards adulthood. The foot becomes deformed and kids start walking on their toes like ballerinas. By the time they get to adolescence, they can no longer walk. From the perspective of a pediatric orthopedist, we want to see the children have relatively normally aligned feet and ankles.”

The components of the new paradigm concept for AFOs includes a foot orthosis insert to protect alignment.

Images: Beverly Cusick

Cusick said that there is abundant literature dating back to the 1960s in the sciences of kinesiology and biomechanics and from clinical researchers, supporting the effectiveness of serial casting and of the new approach to designing AFOs, but pediatric orthopedists rarely read outside their own discipline or invite a thorough discussion. “There are exceptions, of course, but they are rare. While therapists and orthotists can support our concerns and ideas with science and data, the orthopedists seem to feel that consideration of the evidence and providing their own is not necessary to support their management philosophies and choices. Unfortunately, they write the orthotic prescriptions.”

After listening to Cusick’s presentation, Matthews called two pediatric orthopedists to discuss the new approach that he planned on implementing into his own practice.

“They don’t return my calls,” Matthews said. “They have their own techniques. When they see an equinus deformity, they prefer lengthening surgery or a brace at 90° if you can stretch the patient that far and lock them down. I had no luck with local physicians.”

According to Matthews, in order to get a pediatric orthopedist on board with this approach, orthotists must find a way to develop good relationships with them. “Get in there and talk to them and pick their brain,” Matthews said. “I would even tell them, ‘Look, I would like to try this and if the results aren’t there, I will remake the AFOs at 90° and I will remake them for free.’”

Surgery vs. bracing

The new approach to equinus deformity sheds light on another debate among orthotists, physical therapists and pediatric orthopedists: surgery vs. bracing. Surgery is not inevitable for patients with equinus deformity, but according to Miller, children with cerebral palsy who suffer from severe walking problems due to their equinus will likely require two surgeries — one around first or second grade and another at adolescence. “We focus on using braces in ways that allow muscle strength to develop,” Miller said. “If you constantly brace all the time, the muscle shrivels up because it never gets used. After their first surgery, I would have the patient in a brace in school and then on evenings during the weekends. This forces the patient to take the brace off at some point in the day and work on their muscle strength and development. At adolescence, when children are prone to growth spurts, the muscles do not keep up. The vast majority require another surgery to equal the length of the muscles.”

Cusick strongly disagrees with the surgical approach. “Muscles used inappropriately and in wrong joint alignment lose strength. Several studies show that children with CP have weak muscles. Surgery inevitably weakens what is already a weak muscle,” Cusick said. “Recovery to full strength never happens. Recovery to the diminished strength that existed pre-operatively may happen. By attacking the short muscles as if they are the source of the problem, the same movement strategies requiring constant use of the limb muscles for postural control bring on the same contractures.

“Surgery is usually a failure in the long run. I’ve seen many adolescents and adults with CP who are covered in scars and contracted again in all muscles that were lengthened, or they are hypermobile in joints that need stability. They never learned to manage their body weight effectively. Surgery offers a short-term gain in range of motion. Long term it has a high rate of poor outcomes and I can provide recent articles by surgeons that say so.”

Miller contends that a surgical approach does focus on the developmental growth of the patient.

“We need to surgically lengthen the muscle and put them in braces,” Miller said. “That is the pediatric orthopedic approach. We care for the child from 2 years of age to 21. This is not for a 3-month period of his or her life. We try to look forward and plan the treatment so that when they are 20, they’ll be in a good and stable and comfortable position while walking. The goal is to do that without braces but many kids need them into adulthood. The goal is to have the muscle develop strength and the correct length so it can function in the correct physiological position.”

Scientific shortfall

The problem with treating a first- or second-grader now with an eye toward positive outcomes during his or her adolescence is that the pediatric orthopedist does not have experience working with adults. According to Miller, this is one of the inherent problems of the pediatric orthopedic profession. “Pediatric orthopedists don’t have experience with adults and knowing the implications of equinus deformity in adulthood is one of our real deficits,” he said. “There is a scientific deficit. We prescribe braces based on personal opinion and philosophy rather than scientific fact. It doesn’t matter who it is, myself included. There is very little science behind prescribing braces. We try to think scientifically, but when we look at objective data, there is very little behind it.”

The problem is that “we demand quick results from short-term studies for long-term outcomes,” according to Miller. Not many researchers have the patients, funding or time to conduct a study on the implications of bracing that follows 3- or 4-year-old patients with equinus deformity into their adulthood.

“Ideally, it would be nice to have a good scientific background for the braces we order, but the problem is that there just isn’t much out there,” Miller said.

Cusick said the International Society for Prosthetists and Orthotists has developed a comprehensive document on the status of orthotic research and efficacy in their report of a consensus conference on the topic, held in 2008. She said the effectiveness of the “pediatric orthopedic approach” is poorly supported in the document, and the new paradigm shows considerably more promise as a means of promoting improved function.

One goal

Despite their disagreements, the goal of both professions is ultimately the same.

“We have to work together to accomplish the goal,” Miller said. “Everybody is out to do the best they can for the patient. That can only be enhanced by having open discussion.”

Cusick also acknowledged that their debate may start a constructive dialogue between orthotists and pediatric orthopedists regarding equinus deformity management.

“Orthopedists and therapists have routinely approached these children from vastly different bases of information and skills. Open discussion is time consuming. Orthopedists do not attend PT and orthotics conferences unless they are invited speakers. Presentations at most large conferences last 6 minutes. Q&A sessions last 5 minutes. We need time to really talk with each other, to share our information sources, to see clients together, to engage in trials that demonstrate our concerns and nonsurgical strategies. I have yet to see this happen,” she said. — by Anthony Calabro

For more information:

• Cusick, B. Help Patients Manage Equinus Deformity. O&P Business News. 2011;20(5): 74-77.

• Recent Developments in Healthcare for Cerebral Palsy: Implications and Opportunities for Orthotics, UK, 2008. Available at: www.ispoint.org/publications/publications-for-download.html. Accessed January 27, 2012.