By Rebecca St. Andrie

“Having kids makes you more flexible.” It’s a comment most parents make. Recently, it seems to apply to pediatric orthotics as well. The field is becoming more flexible in its outcomes, its devices and its materials. And the results are encouraging: better compliance and more natural gait.

Moreover, there’s a growing flexibility in who to work with. Those making advances talk about collaborating with physical therapists and others outside of O&P in order to determine their goals.

There are still challenges. Some of them are specific to pediatric O&P, such as the slow migration of adult products. Some of them, like the need for better research, are familiar to all of O&P. But to see where the field is growing, keep reading.

Braces that move more
Because of the nature of pediatric orthotics, one push has been to develop braces that are more flexible, with larger ranges of motion. Because pediatric orthotists are dealing with debilitating diseases, their focus is on trying to help the child grow and develop properly. “The goal is habilitation, not rehabilitation,” says Dave Benson, CO, orthotics director at Shriner’s Hospital in South Carolina.

As a consequence, the ability of a brace to allow normal movement becomes extremely important. “If there’s no normal movement, there’s no normal development,” says Bob Meier, CO, BOCO.

“Any time you can unlock a joint, as physiotherapists will tell you, you have to rely less on other joints,” says David Ruthsatz, CO, of Capital Prosthetics & Orthotics Inc. of Columbia, S.C.

Two newly-developed braces—one commercial, one orthotist-developed—show the benefits.

Marcus Cassar, CPO, at Hanger Prosthetics and Orthotics West in Portland, Ore., developed a new upper-limb brace design with Audrey Yasakawa, director of occupational therapy at Laredo Hospital in Chicago.    

Cassar and Yasakawa were interested in finding a better brace for brachial plexus patients so that they didn’t develop typical malalignments. While the bracing they used previously was always good for the wrist and elbow, they struggled with forearm range of motion. Yasakawa remarked to Cassar that the improvements she had achieved through serial casting would disappear, especially as patients reached the last 5-10 degrees of the range of motion.

Working off of a concept first developed by Nicole Parent-Weiss, CO, FAAOP, of the University of Michigan Orthotics & Prosthetics Center, Cassar and Yasakawa came up with a two-part design where the wrist-hand orthosis was independent of the elbow orthosis. (Cassar points out that a different application of this concept is marketed for adults in a brace made by Becker Orthopedics.)

Patients would put on the wrist-hand orthosis first, which would then snap into the elbow orthosis like a gear. That way, says Cassar, “we could click the forearm into various degrees of supination and pronation and then hold it in that position. Once [Yasakawa] had done all this work to get their arms in a good position, we could hold them in that position at nighttime and they wouldn’t lose range.”

Cassar and Yasakawa discovered some other advantages to using the new brace. It reduced the need for serial casting, especially at the end of the range where casting often became prohibitively expensive. It also eliminated the skin issues involved with casting and the need for patients to come back periodically to have the casts removed.

Cassar plans to present the design at the ACPOC meeting and is talking with Ultraflex about producing the brace commercially.

Lower-limb bracing
A similar story is told by Dr. David Ruthsatz. He talks about the Blount’s brace, now offered by JMMR Inc. and Simplicity Systems, used to correct varus bowing of the tibia and femur.

“Before, the knees had to be locked and the kids walked like a tripod,” he said. “That was painful, because there was a lot of rubbing involved.” Moreover, the awkward gait was particularly worrisome.

“When you’re locking the ankle and the knee, you’re asking a lot of the patients and changing their gait tremendously,” he says. “And for a young child, one of the worst things we can do is to change his or her gait for the worse.”

With this brace, the fulcrum force is not just at the knee, but is out over the larger part of the leg. Because of that, the brace can apply the force within any range of motion. Consequently, patients in this brace can bend the knee and have “near-normal gait motion,” says Ruthsatz.

“The complications are almost nil, and compliance is way up,” he says.

Materials
Because a hallmark of pediatric orthotics is dealing with the rapid changes in kids’ growth, memory carbon fiber materials (while not entirely new) are considered by some to be “one of the biggest steps in children’s orthotics.”

It’s the materials’ ability to be modified that makes such a difference for pediatrics. “We can make a change to the orthosis and not have to make a whole new one. If the child improves or needs more support, [the materials allow us to] add to it or take it away,” says Ruthsatz.

This malleability opens up a lot of new possibilities. In states where only one brace is allowed per year, orthotists can modify a brace for a child who has grown and put on more weight, and can bill for their time modifying it. This could increase compliance, says Ruthsatz, and also help the brace work more efficiently.

New for pediatrics
Finally, pediatrics’ smaller market and the challenge of making components smaller, tougher and more adaptable means that much of what is being hailed as new today, the larger field has already seen in another form.

For instance, electrical stimulation devices, such as the WalkAide® and others, are being used on teenagers with success. Likewise, Allard is planning to release a pediatric version of its ToeOff® product.
    
Where the future might go
First, as mentioned above, the pressure for better, smaller, lighter and more adjustable materials is ever-present.

“The technical restrictions and size of components available are a constant challenge,” says Benson. “Moving something a quarter-inch on an adult isn’t a problem, but on children, with their short body frames, it presents a problem.”

Likewise, the chronic problems with skin breakdown that are an issue across all O&P are acute in pediatric orthotics. Often the pressure is greater because the orthosis is trying to correct growing bone.

Several professionals in pediatric orthotics would like to see prosthetic materials, such as silicone gel liners, migrate to orthotics. While foamed polyethylene and silicone materials can be injected into place in orthotics, those in pediatrics would like to have more options.

Second, the movement away from static alignment has raised several research questions about appropriate anatomic posture. “What’s the appropriate pathway of motion?” asks Meier. He would like, for instance, to see if the appropriate anatomic posture for a foot is flat on the ground or able to roll.

Finally, tone continues to be a problem. Meier asks, “How do we create orthotic environments that help mitigate or diminish tone instead of exacerbate it?”

Teamwork brings innovation
It’s not a coincidence that many of the advances in pediatric O&P have been suggested by those who are working in teams. The nature of pediatric orthotics makes this teamwork both more natural and more imperative. Often, the patient has a lifelong debilitating condition with a wide range of symptoms. Constant contact with physical therapists, occupational therapists and physicians has given orthotists a broader perspective.

"We tend to have blinders on,” says Ed Skewes, director of prosthetics and orthotics at Shriners Hospital in South Carolina. “We tend to think that the only thing in [patients’ lives] is prosthetics and orthotics.”

For instance, at the Shriners Hospital limb deficiency clinic, located in South Carolina, a care coordinator will set up one meeting where a family will discuss their child’s case with practitioners, technicians, doctors, nurses, therapists and social workers all at once. The whole group comes up with a plan.

Those involved in such processes say this improves patient outcomes.

“We should rely heavily on the therapists involved, because they wind up spending a lot more time with the families than we do,” says Cassar. “Occupational therapists can speak about how they want the brace to function in daily use for the child.”

For instance, the child’s home life may make the difference between compliance and non-compliance. A patient may look like a candidate for a reciprocating gait orthosis, but learning from the home therapist that there are access problems to the home may change the strategy to having the patient use a standing device only at school.

Physical therapists, also, may be able to give orthotists more accurate information about gait. “If a patient comes in and you think ‘Boy, he’s really tight; he’s going to need more support than what is recommended,’ a physical therapist who works with the child regularly may be able to tell you that the patient’s tone is unusually tight today,” says Benson.

Just like the children it treats, pediatric orthotics is growing and developing. More flexibility in many different areas means better outcomes for patients—and that’s good for all of O&P.

Rebecca St. Andrie is managing editor of the O&P Almanac.