R E S E A R C H R E P O R T

Serial Casting vs Combined

Intervention with Botulinum Toxin
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A and Serial Casting in the

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Treatment of Spastic Equinus

in Children
Melissa Y. Booth, Charlotte C. Yates, Terence S. Edgar, and William D. Bandy
Arkansas Children’s Hospital (M.Y.B, C.C.Y.), Little Rock, AR; Medical University of South Carolina (T.S.E.),
Charleston, SC; and the University of Central Arkansas (W.D.B), Conway, AR

Purpose: Serial casting has been an effective tool used by physical therapists to increase ankle dorsiflexion
range of motion and improve functional gait. The purpose of this retrospective study was to determine
whether injection with botulinum toxin type A (BtA) before serial casting vs serial casting alone was associated
with any changes in (1) the number of weeks necessary to reach the desired dorsiflexion range of motion and
(2) the number of degrees of dorsiflexion range of motion gained per week of casting. Method: Data were
obtained through review of records maintained on patients undergoing serial casting. Thirty subjects com-
prised the two groups of 15 patients each. One group had received BtA before serial casting while the other
group had received no BtA before serial casting. Data were analyzed using two t tests to determine whether
there were significant differences, and the appropriate statistical adjustment (Bonferroni) was applied. Re-
sults: Fewer weeks were required to reach the goal of 15 to 20 degrees of ankle dorsiflexion (or plateau) for
the group receiving BtA than for the group that did not receive BtA. Results also indicated that the group
receiving BtA had a significantly greater increase in range of motion per week than the group that received no
BtA. Conclusions: Using serial casting in conjunction with BtA may achieve range of motion goals in less time
than serial casting alone. (Pediatr Phys Ther 2003;15:216 –220) Key words: retrospective studies, comparative
studies, botulinum toxin type A/therapeutic use, cerebral palsy, child, physical therapy techniques, treatment
outcome

INTRODUCTION benefits of tone modulation and application of adequate

Gait deviations in children with cerebral palsy (CP) stretch in promoting appropriate growth of spastic muscle.
are often directly attributable to length imbalance between Appropriate gastrocnemius length is necessary for ad-
lower extremity agonist and antagonist muscle groups. equate ankle dorsiflexion in swing and at initial contact in
Gage1 proposed that spasticity and abnormal gait patterns stance. Patients without adequate gastrocnemius length
prevent normal growth and contribute to contracture in demonstrate gait deviations, including knee hyperexten-
spastic muscle groups. Gage further discussed the potential sion, and have an increased tendency to show equinus.2,3
Gait deviations described by Donatelli4 attributed to “tight-
ness and shortening of the Achilles tendon” include toe-
0898-5669/03/1504-0216 walking, footflat with calcaneal eversion, and toe-heel gait.
Pediatric Physical Therapy
Copyright © 2003 Lippincott Williams & Wilkins, Inc. Donatelli suggests that musculoskeletal limitations and
limited righting and equilibrium reactions contribute to
Address correspondence to: M.Y. Booth, PT, PCS, Department of Reha- limitations in activation of appropriate motor programs for
bilitation–Physical Therapy, Arkansas Children’s Hospital, 800 Mar- ambulation in children with CP.
shall, Little Rock, AR 72202. Email: mybooth@msn.com
Gossman et al5 provides an extensive review of litera-
DOI: 10.1097/01.PEP.0000096382.65499.E2
ture pertaining to changes in muscle associated with

216 Booth et al Pediatric Physical Therapy

 changes in length. The authors surmised that “applying range of motion. Russman et al14 suggest that the candidate
casts or splints in the lengthened position should add sar- should be “hypertonic, either spastic or dystonic whose
comeres to the muscle fiber and stretch connective tissue abnormal muscle tone is interfering with function or who
elements.” In an article that discusses aspects of muscle is expected to develop joint contracture with growth be-
growth related to CP, O’Dwyer et al6 indicate that the best cause of this abnormal tone.”(p. S186) They further elaborate
treatment to prevent recurrence of contracture would be that to accomplish objectives with BtA intervention, the
suppression of abnormal muscle activity that leads to patient should require treatment of no more than two or
shortening of muscles. three muscles at a time.
One challenge for the physical therapist treating the The physical therapists following patients through
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child with CP is to increase the length of shortened triceps spasticity clinic at this hospital had observed residual lim-
surae muscle group(s), thereby improving the child’s gait itations in ankle dorsiflexion in some patients after BtA
pattern. Serial casting of the ankle, involving application of injections. The residual limitations were observed to inter-
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a series of short leg casts designed to gain ankle dorsiflex- fere with the ability to fully activate muscle groups antag-
ion via prolonged passive stretch, is one such method used onistic to the injected muscles. We began to use serial
to increase muscle length. The use of serial casting as a casting in conjunction with BtA to promote increased
viable method to increase ankle range of motion and gas- range of motion for those patients who did not meet goals
trocnemius length has been documented in patients for for gaining ankle dorsiflexion range of motion via passive
whom a primary imbalance between activation of the dor- range-of-motion exercises and functional movement train-
siflexors and triceps surae exists. Tardieu et al7 found that ing within one to two weeks after BtA injection.
progressive casting was successful in improving ankle dor- In recent years, BtA has been used with increased fre-
siflexion in 10 of 11 children with plantarflexion contrac- quency at our facility, with serial casting prescribed as a
ture in the presence of increased triceps surae activity. treatment adjunct when indicated. Patients receiving serial
Serial casting has been used successfully for more than casting in conjunction with BtA have been observed clini-
a decade by therapists in our facility to gain increased range cally to demonstrate improved quality of movement and
of motion in joints in which tissue extensibility has been gait compared with observations before casting. An appar-
compromised by spasticity. Whether the mechanism for ent reduction in the length of time needed to meet goals for
elongation is through sarcomere addition or through ten- range of motion through a combination of serial casting
don elongation, patients have been observed clinically to and BtA prompted the authors of this study to investigate
improve function in gait after serial casting. whether patients in whom BtA was followed by serial cast-
To allow optimal activation of the anterior tibialis and ing showed greater improvement in dorsiflexion range of
appropriate excursion of the tibia over the talus, the goal motion than patients who received only serial casting.
for range of motion in serial casting of the ankle is ⫹20 We were unable to find reports of studies comparing
degrees of ankle dorsiflexion. If the maximal range of ⫹20 the length of time necessary to achieve an optimal range of
degrees of ankle dorsiflexion is exceeded, the patient is at motion using serial casting when BtA is used compared
risk of developing crouch gait, believed to be due to the with serial casting without the use of BtA. Examination of
inability of the triceps surae to stabilize the ankle in the data available at our facility provides information poten-
presence of excessive length.4 tially useful to therapists and physicians using serial cast-
An additional method to suppress spasticity has been ing in the treatment of patients with range-of-motion lim-
the use of botulinum toxin A (BtA). BtA has been used as an itations related to spasticity of central origin.
effective agent for reducing spasticity in children with in- Therefore, the purpose of this study was to determine
creased muscle tone of central origin. BtA interferes with whether retrospective reports of patients who received in-
the release of acetylcholine at the neuromuscular junction, jection with BtA before serial casting revealed any differ-
resulting in reduced spasticity8 –11 [BtA (Botox) package ences in (1) the number of weeks necessary to reach the
insert, Allergan, Inc., Irvine, CA, 1995]. The physiologic desired dorsiflexion range of motion and (2) the number of
response to BtA at a specific muscle is transient chemical degrees of dorsiflexion range of motion gained per week of
denervation.12 The effects usually last three to eight serial casting.
months.13 Boyd et al12 examined 15 children with a diag-
nosis of cerebral palsy who received BtA to the plantar METHODS
flexors of the ankle. The study showed improved muscle
kinetics including a decrease in excessive plantar flexion Examination and Assessment Protocols
moments in stance in all patients at 12 and 24 weeks after Assessment of muscle tone. In spasticity clinics at
the injections. A significant reduction in muscle tone oc- our facility, patients are followed using an interdisciplinary
curred after three weeks, and an improvement in maximal approach. Patients are examined both by a physical thera-
dorsiflexion was reported. pist and a physician. The physical therapist’s examination
Criteria are present in the literature that provide a includes functional movement assessment, gait analysis,
basis for appropriate selection of patients for the use of BtA. range-of-motion measurements, and assessment of muscle
Leach13 describes the ideal candidate as a patient with in- tone. Range-of-motion measurements are documented
creased tone in a specific muscle group with good passive with the modified Tardieu scale.15,16 When examining and

Pediatric Physical Therapy Serial Casting and BtA for Spastic Equinus 217
 assessing muscle tone, therapists in our spasticity clinic use provide evenly distributed pressure along the plantar sur-
a version of the Ashworth scale17 modified by the authors face of the metatarsal heads. Moderate force was defined as
that involves the use of positive (⫹) signs to note variances a force applied until a firm end feel was felt by the therapist
between the right and left limbs not significant enough to applying pressure. A moderate stretch of consistent pres-
warrant an increase in grade. Noting the variances assists sure was maintained throughout the remainder of the cast-
the physician in decision making regarding dose in specific ing procedure. After application of the plaster layers, rolled
muscle groups receiving BtA. cotton padding was applied. Subsequent layers included
Recommendations are provided by the physical ther- semirigid fiberglass casting tape, rolled cotton padding,
apists regarding which muscle groups appear to be limiting and rigid fiberglass casting tape.
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function most significantly. In completing the clinical as- Casting was initiated at seven to 10 days after BtA
sessment, the physical therapist will also provide recom- injections to allow peak activation of BtA (Botox package
mendations for ongoing intervention to optimize the re- insert, Allergan, Inc., 1995). Casts were changed weekly.
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sponse to BtA including the possible need for serial casting, Casting was continued for each patient until he/she met
orthotics, and equipment. Because of the nature of the one of two criteria: casting was discontinued when R2 of 20
clinic visit, examination and assessment are focused on degrees of ankle dorsiflexion was achieved or when a pla-
aspects of therapy related to spasticity management and teau was reached that was defined as two consecutive casts
do not encompass a total functional or developmental with no increase in the maximal range of motion available.
assessment. Botulinum toxin A. Patients receiving BtA received a
Assessment of range of motion. Range of motion dose of four to six units per kilogram body weight injected
was measured at the ankle joint and reported using the in each gastrocnemius soleus complex in two divided
modified Tardieu scale15,16 for assessing velocity-depen- doses.
dent restrictions designated as R1. R1 is indicative of the
initial point of resistance in the range of motion. Maximal Subjects
range of motion available at the joint is designated as R2. Approval for this study was granted through the Uni-
The use of this examination tool is well described in Boyd versity of Arkansas for Medical Sciences Human Research
et al.18 For purposes of data analysis, only R2 was used. Advisory Committee. Data collection was limited to infor-
Because the use of serial casting requires analysis of gains mation obtained from records of patients who met the fol-
in range of motion, therapists performing casting at our lowing criteria: a diagnosis of CP between two and 18 years
facility receive consistent training in measurement tech- of age who were ambulatory and had not received surgical
niques to be used with patients undergoing serial casting. intervention to reduce spasticity. During the review of
However, interrater reliability for goniometric measure- records, the first 15 patients within each category who met
ments was not determined. criteria were selected. If patients had received serial casting
intervention on multiple occasions, data collection was
Intervention Protocols limited to the data obtained from the initial series of casts.
Serial casting. The casting procedure used at our Thirty patients comprised two groups of 15 patients
facility for gaining ankle range of motion is a procedure each. One group consisted of patients who had not re-
based on techniques described by Cusick19 and is uniform ceived BtA intervention before casting. The mean age of
for patients whether or not they have received BtA. Briefly, patients in the first group was 7.8 years. The second group
the cast consisted of stockinette, padding for bony promi- consisted of patients who had received BtA before serial
nences, a “slipper cast”19 (strips of plaster applied to align casting. The mean age of patients in the second group was
the forefoot with the hindfoot), plaster undercast, rolled 5.6 years.
cotton padding, and two types of fiberglass. Patients were
positioned prone with the knee flexed for application of the Data Collection
cast, allowing the therapist to place the forefoot, hindfoot, Data, which in this study were the number of weeks
and ankle in optimal alignment during casting. required to reach 20 degrees of ankle dorsiflexion or to
Modifications to the original procedure described by plateau and measures of ankle dorsiflexion at the start and
Cusick19 have occurred as therapists at this hospital have end of the serial casting intervention, were obtained
become familiar with the procedure. Modifications in- through a retrospective review of records that were main-
cluded changing the shape of padding for bony promi- tained at our facility on patients undergoing serial casting.
nences and adding layers of rolled cotton padding between Chart review was also used to determine diagnosis and age.
layers to improve ease of cast removal. Material modifica-
tions were standard, and the casting procedure was consis- Data Analysis
tent for all patients in the study. The means and standard deviation for the number of
The stockinette and padding were applied first, fol- weeks to reach 20 degrees of ankle dorsiflexion (or pla-
lowed by application of the “slipper cast,” while the fore- teau) and the change in range of motion of ankle dorsiflex-
foot and hindfoot were maintained in as close to neutral ion were calculated for each group. One independent t test
alignment as possible. A stretch into dorsiflexion was pro- was performed to compare the number of weeks of casting
vided by applying a moderate stretch with care taken to required in the two groups. A second independent t test

218 Booth et al Pediatric Physical Therapy

 was used to compare the number of degrees of ankle range proximal and distal control. Additional research, relevant
of motion gained after casting in each group. Using a Bon- for this patient population, should include objective exam-
ferroni correction factor for use of multiple t tests, signifi- ination of these improvements in gait.
cance was accepted at p ⬍ 0.025. Of interest as well would be comparison of long-term
gross motor and gait improvements in the patient popula-
RESULTS tion receiving BtA and serial casting with patients not re-
The mean for the number of weeks required to reach ceiving these interventions. Investigation of long-term out-
the goal of 20 degrees of ankle dorsiflexion (or the plateau comes would provide beneficial information to physicians
that was defined as no change in range of motion for two and therapists treating patients with spasticity.
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consecutive weeks) was 1.95 (⫾ 1.13) weeks for the group Ongoing examination of patients to determine the
that received BtA and 3.55 (⫾ 1.16) weeks for the group that need for repeat procedures even after goals have been met
did not receive BtA. An independent t test indicated that the for range-of-motion gains is indicated. Clinical experience
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difference between the two groups was significant (t ⫽ 3.80, has shown that shortening in agonistic spastic muscle
df ⫽ 28, p ⫽ 0.01). groups may recur, especially after a period of rapid growth.
The statistical tests also indicated that the BtA group Clinical observation of patients followed through our spas-
had a significantly greater increase in range of motion per ticity clinic has revealed that patients often have unpredict-
week than the group that did not receive BtA (t ⫽ 2.42, able losses of range of motion and should be followed rou-
df ⫽ 28, p ⫽ 0.02). The mean increase in range of motion tinely to provide interventions in the timeliest manner.
per week for the BtA group was 9.19 degrees and 5.54 Examination of data in this study revealed that both the
degrees for the non-BtA group, with a standard deviation of BtA and non-BtA groups contained patients for whom cessa-
5.62 and 3.87, respectively. tion of casting occurred due to reaching a plateau rather than
the desired 20⫹ degrees of ankle dorsiflexion. When serial
DISCUSSION casting and BtA are used as interventions, therapist and phy-
Management of patients with spasticity requires careful sician discretion should be used to determine whether the
consideration of options available for contracture manage- range of motion achieved is functional for each individual
ment. Both serial casting and injection with BtA have been patient. For patients not achieving functional range of mo-
used as separate, effective treatment techniques to reduce tion, an orthopedic referral may be indicated.
contractures in patients with CP5,11–13 (Botox, package insert, A limitation to the study was the lack of establishment
Allergan, Inc., 1995). Results of this study suggest that opti- of reliability in goniometric measurement of ankle dorsi-
mal gains in range of motion in individuals with CP may be flexion. Although therapists performing casting at our fa-
achieved by combining the interventions. Achieving range of cility receive consistent training in measurement tech-
motion in a shorter time frame could allow decreased time for niques using the goniometer, no actual test-retest analysis
immobilization of the joint and a more timely transition to of reliability occurred before the data collection. Obvi-
orthotic management. In addition, increased opportunities ously, the design of this retrospective study would have
are available for activation of antagonistic muscles during the been strengthened if such reliability were established. As
optimal effective period for BtA when range of motion im- we have learned from performing this study, any clinic that
provements occur more quickly. desires to perform such research needs to routinely assess
Due to the retrospective nature of this study and the and ensure appropriate reliability of measures to enhance
lack of control of all variables, the results of this study do clinical outcome research in physical therapy.
not provide conclusive evidence of the efficacy of serial
casting used in conjunction with BtA. However, this study
and our clinical observations do suggest that patients are CONCLUSIONS
able to achieve range of motion goals during serial casting Results of this retrospective study indicate that using
more quickly when receiving BtA than when not. Further BtA in conjunction with serial casting was more effective
study would be necessary, using more formally established than serial casting alone in gaining ankle dorsiflexion in
parameters in data collection and a randomized control patients with CP. Patients in this study who had received
trial of the various types of treatment to definitively com- BtA before casting required less time for completion of the
pare the effects of serial casting without BtA with serial course of casting and made more rapid gains in range of
casting with BtA. motion in each week of casting. The development of a
Clinical observations have indicated that patients re- future study based on treatment protocol used in this study
ceiving BtA in conjunction with serial casting of the ankle is encouraged.
have shown significant improvement in gait patterns in-
cluding improved active ankle dorsiflexion in swing, im-
proved heel placement in initial stance, achieving foot flat ACKNOWLEDGMENTS
in mid-stance, and decreased genu recurvatum in mid- and The authors thank Beth McKitrick-Bandy, MA, PT,
terminal stance. Therapists at this hospital have observed PCS, and the staff physical therapists at Arkansas Chil-
in long-term follow-up progressive improvement in overall dren’s Hospital, Little Rock, AR, for their support and con-
motor patterns and quality of movement with improved tributions in the completion of this article.

Pediatric Physical Therapy Serial Casting and BtA for Spastic Equinus 219
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220 Booth et al Pediatric Physical Therapy