Pediatric Orthoses – An Overview for DPT Students

A Summary of Orthotics for the Pediatric Patient

Capstone project cumulating in a voice thread presentation for DPT Students
By: Martha Kalisz, SPT

Background

I plan on working in a pediatric setting, and, in my experience, many pediatric patients who require physical therapy services also benefit from, or would benefit from, the use of orthotic devices as an ambulation aid. During clinical rotations, I have worked with patients with a variety of diagnoses who benefit from orthotics, including cerebral palsy, spina bifida, idiopathic toe walking, down syndrome and other genetic conditions. Although each case is unique, there are general benefits in choosing one orthotic device over another. I have seen orthotics that work beautifully, and others that needed some modification in order to benefit the patients. My clinical instructor was extremely helpful in helping me to decide which orthotic device to recommend for each patient when I was on rotation, and I saw how closely she was able to work with the orthotists in order to customize the orthotic to maximally benefit each patient. I hoped to learn more about pediatric orthotic devices so that when I begin practicing I will be able to confidently recommend certain devices, and educate patients and their families about proper use and fit.

Project Overview

The plan for my project was developed in conjunction with Dr. Dana McCarty based on the curriculum for PHYT 880, Child and Family Assessment, an elective course for students hoping to practice in pediatrics. My project aimed to create doctoral level coursework to help students better understand the indications for and purposes of a selection of commonly used orthotic devices in order to better understand how to choose orthotic devices for pediatric patients.  I started this in EBP II by reviewing literature comparing orthotic types used to improve toe walking. The summary of the pertinent articles I appraised can be found here: EBP II Evidence table

My literature review revealed a lack of quality as well as quantity of evidence relating to pediatric orthotic devices as they pertain to treatment of idiopathic toe walking, as well as toe walking in general. A summary of my findings can be found here: CAT Synthesis and Clinical Implications

Statement of Need

Many children who require outpatient physical therapy services due to inefficient gait either use or may benefit from orthotic device use.^1,2 Physical therapists should be knowledgeable about the use of orthotic devices, and how to make or asked for adjustments to be made in order to ensure our patients are getting the most benefit from them. Different orthotic devices can allow or restrict motion in various degrees, making them more or less applicable for certain diagnoses or gait abnormalities.^2,3 The vast array of orthotic devices that may be chosen can be a daunting decision for entry level physical therapist, even after strong clinical rotations.

My time in clinical rotations focusing on pediatric patients revealed to me the importance of general orthotic knowledge for the practicing pediatric physical therapist. Orthotic devices are commonly prescribed to patients for a variety of diagnoses and reasons, and it is important to be able to confidently answer questions from patients and their families. Due to the lack of evidence for orthotic treatment options for a common pediatric diagnosis as found in my literature review^4,5, combined with my perceived importance of orthotic knowledge for entry-level practitioners hoping to work in pediatrics, for my capstone I decided to make a narrated voice thread lecture outlining commonly used pediatric orthoses and their indications. As part of the project, I took photographs and filmed patients who use orthotic devices, and these were integrated into the voice thread as case studies. I then created a narrated voice thread describing common uses for commonly prescribed orthotic devices and applications for the entry level physical therapist.

Products

A simplified version of the PowerPoint I made in conjunction with my voice thread can be found here: Pediatric Orthoses Part 1, Pediatric Orthoses Part 2, Pediatric Orthoses Part 3, Pediatric Orthoses Part 4, Pediatric Orthoses Part 5, Pediatric Orthoses Part 6

The voice thread contains additional photographs of pediatric patients with conditions which warrant orthotic use, as well as video of multiple patients walking with and without their orthotic devices. Due to patient confidentiality of pediatric patients, I am unable to post my completed voice thread or full-version PowerPoint to this public domain with those photos and videos. These additional materials are available to the entry level and transitional DPT students who take the PHYT 880 elective course.

The videos of the children walking are intended to help students become more confident with pediatric gait analysis, as well as to help them to identify how orthotics may affect gait dynamics. In order to assess the student’s level of competence with these skills, I developed a discussion board assignment. Each student will be required to post an answer and respond to a classmate’s post. The assignment can be found here: Discussion Board Question

Evaluation & Reflection

I sought evaluation information from my committee, as well as students who had previously taken the PHYT 880 elective course. Results of this feedback are tabulated here: Survey Results

In producing my capstone, I have been able to improve my own clinical knowledge, and hopefully have produced a valuable product for future students. I gained valuable experience observing in the clinic with Dr. DeGrauw, taking through pediatric gait analyses, and working with her to learn about why specific orthoses were helpful for each specific child. I learned more about specific orthoses and indications for each through my research and discussions with Dr. McCarty and Dr. Gross. Overall, I now feel more comfortable with a topic that I once found challenging. I hope that this knowledge will ultimately translate to clinical practice to help me to become a more effective therapist. Finally, creating a voice thread and other doctoral materials has given me insight into producing and teaching materials at a high level. I consider these experiences invaluable, and hope that others will also be able to use the products to further their knowledge.

Acknowledgements

I would like to thank my capstone committee, Dr. Dana McCarty, Dr. Michael Gross, and Dr. Erin DeGrauw for their guidance and insight. Dr. McCarty has been a fantastic mentor throughout the DPT program, and was an instrumental part of this project, providing vision, feedback, and guidance throughout. As my capstone advisor, Dr. Gross provided helpful feedback at multiple stages of the project and added his orthotic expertise as an extra layer of depth and clinical reasoning. Dr. DeGrauw added her expertise as a pediatric therapist, and was in instrumental part of filming and gait analysis. Finally, I want to thank the families and children in the photos and videos for their time and kindness throughout filming.

Resources

1. Romkes J, Brunner R. Comparison of a dynamic and a hinged ankle-foot orthosis by gait analysis in patients with hemiplegic cerebral palsy. Gait Posture 2002;15(1):18-24.
2. Herndon SK, Bennett BC, Wolovick A, Filachek A, Gaesser GA, Weltman A, Abel MF. Center of mass motion and the effects of ankle bracing on metabolic cost during submaximal walking trials. J Orthop Res 2006;24(12):2170-2175. doi:10.1002/jor.20292.
3. Carmick J. Forefoot mobility in ankle and foot orthoses: effect on gait of children with cerebral palsy. Pediatr Phys Ther 2013;25(3):331-337. doi:10.1097/PEP.0b013e31828e30ac.
4. Herrin K, Geil M. A comparison of orthoses in the treatment of idiopathic toe walking: A randomized controlled trial. Prosthet Orthot Int 2016;40(2):262-269. doi:10.1177/0309364614564023.
5. Lam WK, Leong J, Li Y, Hu Y, Lu W. Gait & posture: Biomechanical and electromyographic evaluation of ankle foot orthosis and dynamic ankle foot orthosis in spastic cerebral palsy. Butterworth-Heinemann; 2005;22:189.