PHILOSOPHY OF THERAPEUTIC CASTING
As physical and occupational therapists, we have the privilege to be in service to individuals with neurological and muscular diagnoses, helping to manage their movement system impairments through a course of rehab, development, and possibly over a lifetime. It is important to support the autonomy of patients, especially young or vulnerable patients who may have decreased abilities to make choices in their lives and particularly to set boundaries around their bodies. We establish that the patient is the “team leader” of casting, who selects the color/design, and is given the opportunity to participate and make choices within the casting process. Strategies to decrease patient stress are woven into the Therapeutic Casting casting process. This functions to lower stress, decrease pain and tonic muscle contractions around the involved joint, and improve outcomes. We strive to avoid literally adding “insult to injury” with ugly casts or splints.
PATIENT CENTERED CARE
The musculoskeletal system is prone to impairments and varied clinical presentations even in the absence of neurological impairment. Among patients with a given joint restriction, there may be a wide range of contributing drivers, limiting structures, and compensations. Clinicians must perform differential diagnosis including bony structures, soft tissue extensibility, muscle length, joint function, and relative stiffness contributing to motion limitations to appropriately direct the casting process.
SPECIFICITY OF MOTION: Identifying directional susceptibility to movement and relative stiffness.
In a multi-joint system, such as the ankle, compensatory movement patterns will often occur secondary to joint restrictions. Clinicians must determine over-stretched structures and directions susceptible to motion, and be careful to direct forces to restricting structures while increasing movement at the target joint.
SPECIFICITY OF MOTION
MANUAL INTERVENTION TO PREPARE THE SYSTEM FOR CASTING
Pediatric and neurologic physical therapists should work as manual therapists, skilled in assessing and treating the mechanical capacity, neuromotor function, and motor control of the movement system with their hands. A manual therapy approach to serial casting, which incorporates principles of the extensive body of work of the adult orthopedic manual therapy community is vital to improving outcomes and reducing pain. Pediatric and neurologic patients to not cease to have joint and connective tissue dysfunction as well as changes in muscular function and length.
MANUAL THERAPY APPROACH
EFFICIENT AND EFFECTIVE TREATMENT
Efficient use of the therapist’s body in line with the target structures of the patient maximizes efficiency, clinical efficacy, and safety for both patient and therapist.
EFFECTIVE EFFICIENT TREATMENT
SPECIFIC, SEGMENTAL APPLICATION
Modern materials have advanced the complexity of forces that can be applied using a cast to address specific restrictions. Segmental application allows forces to be directed to target structures at each joint in a system.
SPECIFIC SEGMENTAL APPLICATION
PRINCIPLES OVER PROCESSES
The parable of the pot roast: A mother was teaching her daughter how to make a roast. After seasoning, she explained “Then, you cut the ends off the roast and place it in the pan.” “Why do you cut the ends off the roast, Mom?” asked the girl, and the mom replied that it was an important part of the process. With further questioning, they agreed to contact the girl’s grandmother to ask her why. She again repeated it was a crucial step. This continued, until they finally reached the girl’s great-grandmother, who stated, “I don’t know why you guys cut the ends off your roast, I used to do it because my pan was too small.”
When asked why a step during the casting process is being performed, the answer should never be “because that’s what the manual said,” or “that’s what the instructor taught me.” Learning the relevant principles of biomechanics, joint and soft tissue restrictions, manual therapy, and safe, effective use of materials is much more important than memorizing steps. Step-by-step techniques are provided as a guide during courses, but may require modification depending on the needs of each patient/pan. Standards are important to prevent harm, but clinicians must individualize care as well as allowing for new ideas and evidence to influence their practice. Remember to be the granddaughter and ask “why?” and “why not?”.
It is important that processes are named in literature and documentation, but testing the efficacy of each step in a multi-step process for a heterogeneous patient population would be impossible. The clinician must be guided by clinical reasoning at each step of the process.