Pediatric Physical Therapy:
Letter to the Editor
Private Practice, Alamo, CA
To the Editor:
I thank the authors of this focused study, “Single-Subject Design Study of 2 Types of Supramalleolar Orthoses for Young Children with Down Syndrome,”1 for helping the pediatric community understand the importance of observing the effect of orthoses. They found that extending the plastic distal to the metatarsal heads changes the effect of the supramalleolar orthoses. This orthosis is often thought not to be effective because it does not control the ankle. However, the authors have shown that it can be effective if the medial plastic does not extend distal to the metatarsal heads.
The authors mentioned that Selby-Silvestein et al2 found that it was beneficial to not extend the plastic beyond the metatarsal head on the medial and lateral sides, which has also been my experience with children with Down Syndrome and cerebral palsy. The extension on the lateral side, called a gait extension, is usually used to correct intoeing of gait. This may have been beneficial for the one child or perhaps the child just managed to compensate for this.
It is important that the PT evaluate and see if the child does better without blocking the toe-break or just blocking one side of it in any orthoses that the child is using.3 The blocked rocker prevents heel rise and the children have to be strong enough to compensate for that loss of mobility. The child in this report was not yet walking and was 4 months younger than the child who was able to tolerate the block. It would seem that the younger child was too weak to compensate.
It is every easy for the PT to cut back on the Cascades plastic as shown in the Figure. This is frequently done in my clinic as it is very difficult for Cascade to see in the mold exactly where toe-break occurs. The solution is to just cut away the block and then the Cascade DAFO will not force the child to compensate and it will be easier to walk. The triangle that is removed appears too small to make any difference, but it may make all the difference in many children between walking and not walking or walking with unwanted compensations.
Judy Carmick, MA, PT
1. Tamminga JS, Martin KS, Miller EW. Single-subject design study of 2 types of supramalleolar orthoses for young children with Down syndrome. Pediatr Phys Ther. 2012;24:278–284.
2. Selby-Silverstein L, Hillstrom H, Palisano R. The effect of foot orthoses on standing posture and gait of young children with Down syndrome. NeuroRehabilitation. 2001;16:183–193.
3. Carmick J. Unblocking the forefoot rocker in foot orthoses: effect on gait of children with spastic cerebral palsy. Pediatr Phys Ther. In review.