Best practice for serial casting to increase ankle range of movement following Botulinum Toxin in children with Acquired Brain Injury.

Purpose

Loss of range of ankle movement is commonly seen in children following acquired brain injury (ABI), due to altered muscle tone and prolonged periods of immobility. Reduced ankle range of movement can impact a child's ability to sit and stand, and therefore participate in all areas of daily living.


Serial casting following Botulinum Toxin injections (Botox) is recommended when injections are used with the goal of increasing range of movement. Although casting was routinely used in this rehabilitation setting, there were inconsistencies in the timescales, duration and frequency of casting post injections.

Aim:To develop and pilot a local protocol for serial casting post Botox, based on a review of evidence and expert opinion.

 

Range of movement improved
from -40o dorsiflexion to neutral on the left, and -45o dorsiflexion to neutral on the right.
...and a 19% score improvement
in Physical Abilities and Mobility Scale measure.

Approach

A scoping approach to gathering evidence was undertaken including a systematic review of the literature, and consultation with Physiotherapists and Occupational Therapists working with children with ABI in the UK, USA and Canada.

A multi-disciplinary team at The Children's Trust convened to consider current practice in light of all the evidence available for upper and lower limb serial casting.

A protocol was developed and piloted with a 7 year old with a severe ABI following encephalitis.

Outcomes

Limited evidence for casting protocols in children with ABI following Botox exists. Differences in casting protocols were found, including length of time between injection and casting (1-14 days) and application length (2-14 days).

Some evidence recommended joints were cast approximately 10o off maximum range, whilst others advocated end of range. In different services, different professionals lead on casting, including medics, plaster room technicians and therapists. A local protocol was written based on available evidence.


As per the new protocol, therapists led casting for the 7 year old child. Casting was undertaken at 10 days post Botox. Casts were made at maximum range and changed bi-weekly for 5 weeks until changes in range ceased.

Range of movement improved from -40o dorsiflexion to neutral on the left, and -45o dorsiflexion to neutral on the right. This enabled her to sit with feet in neutral on footplates, stand in a prone standing frame, avoid orthopaedic surgery and contributed to the achievement of her goals, and a 19% score improvement in Physical Abilities and Mobility Scale measure.
 

A protocol has been developed and implemented into local practice, which has improved the consistency of practice. A case study has demonstrated how the protocol has been used positively

Implications

A lack of consensus for best practice for casting following Botox exists. The protocol will need to be audited and reviewed locally, ensuring it is embedded into practice.

Additionally, research is required to test and compare the intervention in terms of the parameters used to form an evidence base.

Funding acknowledgements

Unfunded

Additional notes

This work was presented at Physiotherapy UK 2019