Serial Casting

We first heard about serial casting during our son's month of intensive pediatric therapy. His PT told us about children they had worked with who were able to postpone or avoid surgery for muscle tightness using this approach.

Serial Casting - quoted from St. Joseph's Children's Hospital of Tampa

"Serial casting is a noninvasive procedure that helps children and adults improve their range of motion so they can perform daily activities with less difficulty. It is a process in which a well-padded cast is used to immobilize a joint that is lacking full range of motion. The cast will be applied and removed on a weekly basis. Each cast gradually increases the range of motion in the affected joint.

Who benefits from Serial Casting?
Muscle tightness can manifest itself in many ways and for various reasons. Doctors refer patients for serial casting to help improve overall quality of life. Serial casting helps patients who have a variety of disorders including:

• Cerebral palsy
• Spina bifida
• Brain or spinal cord injury
• Congenital abnormalities
• Muscular dystrophy
• Idiopathic toe walking
• Peripheral neuropathy

Why would a physician refer for Serial Casting?

• Serial casting is a non-surgical approach aimed at reducing muscle tightness around a joint that is limiting range of motion and functional mobility.
• Serial casting assists in achieving the optimum alignment of a joint. It also helps prepare a joint for the use of further orthopedic devices such as braces, splints, etc.
• Serial casting may help decrease the chance of a deformity developing and/or progressing due to abnormal weight-bearing.
• Serial casting is a safe and effective way to increase range of motion and improve functional mobility. It may help eliminate, delay, or minimize the need for surgical intervention.

What happens during a Serial Casting session?
Muscle strength and range of motion of the affected joint will be assessed prior to application of the cast. A team of specially trained therapists will apply the cast in the joint’s optimal position and range. Instruction about care of the cast and precautions will be reviewed with the family and patient.

How long will I need to come for cast changes?
Casts will be changed on a weekly basis until a target range-of-motion goal is achieved. Predicting the number of casting sessions is difficult, as each individual responds to the casting procedure at different rates. Typically, the casting procedure is completed in 4-6 weeks.

What happens after the casting is finished?
The physician determines what may be needed in terms of orthotics (braces, splints, etc.) to help maintain the newly gained range of motion.

How does Serial Casting affect the patient and family?
A short accommodation time will be required, as the cast has added weight and the joint is now immobile. A walking cast and cast shoe allow children to walk during the period of casting. Daily routines are not altered significantly and patients can stay very active, participating in school and normal activities. The biggest challenge is keeping the cast dry. Sponge bathing is necessary to avoid getting the cast wet."

Phosphatidylcholine (PC) : PhosChol

Phosphatidylcholine (PC) is a phospholipid and a major source of choline. I found out about a PC supplement, PhosChol, from a fellow parent who has a son diagnosed with Guanidinoacetate methyltrasferase deficiency. You can read more about John at Mommy Klor. After consulting with a doctor, I started giving the supplement to our son on 05/06/09.

It's been about two weeks, and our son seems to be opening and using his hands more than before we started the choline supplement. One of his therapists comment recently that he's using his hands and keeping them open more than before. It's hard to conclusively say that it's only the choline supplement, but his hand improvements seem to correlate with the introduction of PhosChol.

Doctors at the University of Colorado are seeing if choline taken during pregnancy by mothers can prevent mental illness in children. You can read more about their work at Choline Baby.

Botox : FDA instructs manufacturers to add boxed warning about possible negative effects

Botox has been used by doctors in recent years to help manage muscle spasticity. I've heard many success stories and some warnings about using Botox to treat spasticity. I don't have any personal experience with this use of Botox and our son's physiatrist has never mentioned that he would recommend it for our son. I've included links and quotes below from a few sources, including the FDA. Hopefully this FDA warning will help parents make informed decisions about their children's treatment.

Botox helps kids with CP
"...the drug forces the stronger contracting muscles to relax, a condition that lasts for a few months. During that time, physical therapists can work with the child to develop the weaker muscles that control extension. Although it's not appropriate for all children with CP, the treatment may help some move normally."

The Latest on Botox for Cerebral Palsy
"The FDA, which has never approved botulinim toxin for this use, issued instructions to manufacturers to add a boxed warning on labels about possible negative effects."

"Will these precautions make you less likely to seek this treatment for your child? Or have you had such success with it that you're willing to take the risk?"

Follow-up to the February 8, 2008, Early Communication about an Ongoing Safety Review of Botox and Botox Cosmetic (Botulinum toxin Type A) and Myobloc (Botulinum toxin Type B)
"As the result of an ongoing safety review, FDA has notified the manufacturers of licensed botulinum toxin products of the need to strengthen warnings in product labeling, and add a boxed warning, regarding the risk of adverse events when the effects of the toxin spread beyond the site where it was injected."

"Botulinum toxin products have been approved by FDA for one or more of the following uses: temporary improvement in the appearance of glabellar lines (frown lines between the eyebrows), treatment of strabismus (crossed eyes), blepharospasm (abnormal tics and twitches of the eyelids), cervical dystonia (involuntary sustained or repetitive contraction of the neck muscles), and primary axillary hyperhidrosis (severe underarm sweating). For these uses, botulinum toxin is injected into the skin or into muscle tissue."

"In pediatric postmarketing adverse event case reports, botulinum toxin products were mostly used to treat muscle spasticity in cerebral palsy, a use that has not been approved by the FDA. The reported cases of spread of botulinum toxin effect beyond the site of injection were described as botulism, or involved symptoms including difficulty breathing, difficulty swallowing, muscular weakness, drooping eyelids, constipation, aspiration pneumonia, speech disorder, facial drooping, double vision, or respiratory depression. Serious case reports described hospitalizations involving ventilatory support and reports of death."

"...healthcare professionals who use botulinum toxin products should understand that these adverse events have been reported as early as several hours and as late as several weeks after treatment."

Allergan to Resolve Botox Safety Labels
"Most deaths and serious problems were seen in children treated for cerebral palsy-associated limb spasticity, the FDA said."

Blues for Botox? 'Black box' warning, slumping economy, competitors may impact dominance
"Typically reserved for medications associated with serious or life-threatening risks, the "black box" warning is one of the strongest safety actions the agency takes. The FDA noted that problems with botulinum toxin had occurred mainly in patients receiving overdoses for unapproved therapeutic treatments, such as use in limb spasticity in children with cerebral palsy."