Casting Protocols for the Upper and Lower Extremities.

Casting Protocols for the Upper and Lower Extremities

Goga-Eppenstein P, Hill J, Philip P, et al. Gaithersburg, MD 20878, Aspen Publishers Inc, 1999, hardcover, 205 pp, illus, ISBN: 0-8342-0763-X, $65.

This book guides physical therapists and occupational therapists in the use of casts for upper- and lower-extremity contractures and hypertonicity. The primary focus is on developing clinical competency in casting techniques. The authors also discuss some of the physical, pharmacological, and surgical interventions available for treating spasticity, some of which are used in conjunction with casting.

Chapter 1 summarizes the theoretical background and rationale for cast interventions. The authors review the neurological and physiological mechanisms and current hypotheses that provide the basis of casting as a rehabilitation technique. Although the chapter is quite brief (only 3 pages), it is well referenced.

Chapter 2, "Precautions and Competency in Cast Application," describes the casting process as a whole. Precautions that therapists should take throughout the casting process--including assessment of skin integrity and sensitivity, assessment of circulation in the involved extremity, determining the ability of patients to tolerate the procedure, and providing instructions to caregivers--are briefly discussed. In this chapter, the authors suggest that plastic bags can be secured over the casted extremity to protect it from moisture during bathing. However, I have not found this method to be particularly successful, and the authors are not specific about the best way to secure the bags over the cast. In this chapter, the authors also suggest methods that experienced therapists can use to promote competency among staff. Readers are referred to several appendixes in the back of the book for sample policies, procedures, and data recording forms used to monitor competency and outcomes.

The next 3 chapters are dedicated to casting the upper extremity. Chapter 3 provides an overview of the types of casts used to manage contractures or hypertonicity and movement patterns in the upper extremities. Chapter 4, "Upper Extremity Assessment," describes the factors to be considered when deciding to cast, and discusses precast and postcast assessment components. These assessment components include passive range of motion, sensation, muscle length, muscle contracture versus joint limitations, tonicity, motor control, functional use, baseline skin condition, and circulation. Chapter 5 describes the application of 8 different casts: (1) rigid circular elbow cast, (2) elbow drop-out cast, (3) rigid circular wrist cast, (4) long arm cast, (5) finger shell cast, (6) platform cast, (7) thumb enclosed cast, and (8) metacarpophalangeal wrist cast. The rationale for the use of each cast, the casting materials required, and step-by-step application instructions are included. Photographs of each step of the process complement the text.

Chapters 6 and 7 are dedicated to casting of the lower extremity and follow the same format as the chapters for the upper extremity. Chapter 6 discusses the appropriateness of casting as an intervention and lower-extremity assessment. Additional topics include considerations for serial casting, indications and contraindications for serial short or long leg casts, and indications for dynamic weight-bearing casts. In chapter 7, the rationale, casting materials, and fabrication procedures are included for 5 casts: 2 variations of short leg serial casts, with and without a slipper mold; the serial knee cast; the "tone-reducing" footplate; and the supramalleolar orthosis. As in the chapters on upper-extremity casting, photographs are included to demonstrate each casting process.

Chapter 8 describes cast removal tools and techniques and bivalving procedures, which allow the casts to be used as maintenance orthoses. In chapter 9, "Considerations With Specific Diagnoses," several case studies illustrate the use of casting as an intervention technique. Case studies for individuals with cerebral palsy, brain injury, spinal cord injury, burns, and juvenile rheumatoid arthritis are included. Chapter 10, "Medical Management of Spasticity," presents a very brief overview of current approaches to managing spasticity, including physical modalities, pharmacological interventions, nerve blocks, botulinum toxin injections, selective posterior rhizotomy, and orthopedic procedures. Although the interventions are not discussed in great depth, there is an extensive reference list, with over 100 references given for this chapter.

The final chapter discusses the option of orthopedic surgery to improve motor control of the upper extremity when the benefits of a standard rehabilitation program have reached their limits. Brief sections on assessment and surgical indications and contraindications are included. It reviews a few of the more commonly used procedures that address elbow flexion contractures, forearm pronation contractures, wrist and finger flexion contractures, and thumb deformities. Classification systems that assist practitioners in evaluating these specific impairments are included as guidelines on which to base recommendations for surgical intervention. The use of an upper-extremity cast prior to surgery is suggested as one means of selecting the most appropriate operative procedure.

The book concludes with 10 appendixes, including policy and procedure guidelines for both physical therapists and occupational therapists involved in casting, upper- and lower-extremity casting competency check-out forms, an interdisciplinary policy for cast removal by staff other than physical therapists or occupational therapists, a casting program worksheet, a casting quality monitor log, a sample consent form for casting, a sample cast-care-and-precautions form for caregivers, an emergency department physician letter for cast removal, and a list of vendors who supply casting materials and equipment.

This book is very well organized. The format for chapters with similar content is consistent throughout. Excellent photographs depicting the fabrication of each cast significantly enhance the book's value as an instructional tool. Although they are only brief overviews, the chapters on medical management of spasticity and upper-extremity surgery are nice additions to the book and complement the main subject well. The appendixes are also excellent adjuncts to the text and could easily be adapted to any setting.

If there is one weakness that I could identify in this book, it is that there is very little discussion regarding differences between the use of plaster and fiberglass as casting mediums. All of the casting procedures are demonstrated with plaster. The use of fiberglass is mentioned only when differences in drying time and techniques for cast removal are discussed. I would have found it helpful if the advantages, disadvantages, and specific differences in cast fabrication techniques using both materials had been included.

Overall, I found this book to be an excellent reference for any clinical setting in which casting is a regular part of clinical rehabilitation services.

Gretchen Meyer, PT IPMR/Easter Seals-UCP Peoria, Ill

Ms Meyer is an area supervisor at Easter Seals-UCP and an adjunct clinical instructor at the Bradley University physical therapy program. She specializes in the assessment and treatment of children and adults with developmental disabilities.