children with spina bifida develop a wide variety of congenital and acquired orthopedic 
 deformities including knee flexion contractures .
knee flexion contractures in children with 
 spina bifida affect children s functional activities and interfere with the ability of 
 children to transfer and walk1 .
a limited number of studies have looked at the management of knee flexion contractures in 
 children with spina bifida .
surgical intervention is the most effective choice for 
 correcting joint contracture in children with spina bifida2 , 3 .
however , with surgical 
 intervention there is a great potential risk of complications arising from anesthesia and 
 the varying skills of surgeons4 .
serial 
 casting is the process of successfully applying and removing corrective plaster of paris 
 casts to increase extensibility in the soft tissues surrounding the casted joint5 .
serial casting for improving range of 
 motion in the knee joint has been used in conditions such as cerebral vascular accident 
 ( cva ) , traumatic brain injury ( tbi ) and pediatric cerebral palsy6,7,8 .
these previous studies show that serial casting can increase joint 
 range of motion , muscle extensibility , and improve functional mobility .
however , to date , no 
 work has specifically looked at the use of serial casting in the management of children with 
 spina bifida , and there is a lack of documented evidence on the long term benefits of serial 
 casting apart from the evaluation at the time of the final cast removal .
hence , the purpose 
 of this case report was to describe for the first time , the use of serial casting in the 
 management of knee joint flexion contracture in a young child with spina bifida , with 
 follow - up to document the long term benefit of serial casting after one year .
the child was 6  years old with normal cognitive abilities , and had l3l4 spina bifida level 
 lesion with quadriceps muscle strength grade 3 + .
the child was born through a normal 
 vaginal delivery and had normal developmental milestones . at 4  years
old a clinical 
 examination revealed there was an associated history of neurological weakness , gait 
 abnormalities and urinary and bowel incontinence
. neurological examination revealed reduced 
 sensation to pain and touch in the distribution of l3l4 nerves .
the child was referred for 
 physical therapy intervention for the first time at 4  years old with lower limb joint 
 contractures including knee flexion contractures .
physical therapy training included : manual 
 stretching exercise and prolonged stretch through strapping on a tilt table or application 
 of sandbag weights over the distal femur .
physical therapy training was conducted in one 
 hourly session per week by a trained physical therapist but no improvement was seen . 

pre - intervention testing was completed one day prior to intervention which consisted of 
 standard goniometer measurement and was used to measure the childs knee joint ranges of 
 motion ( rom ) before and after casting over 4 weeks . the universal goniometer ( ie .
the child s parents signed an informed consent statement that had been approved by the 
 al - hussein center ethical committee and al - hashmite university research committee board .
the 
 child s legs were immobilized in a long cast from the thigh to the ankle ( fig .
the serial casting technique applied in this study was modified to be appropriate for a 
 child with spina bifida .
children with spina bifida are usually prone to decubitus ulcers 
 and other types of skin breakdown , especially on bony prominent areas10 .
careful measures were taken to avoid bed sores or other 
 complications which may occur with casting .
one of these measures included reduction of cast 
 interval changes ; the duration was reduced to two to three days .
p.o.p is cheap , strong and radio translucent but the limb can not be 
 inspected . in order to avoid skin breakdown and friction between the cast and the child s 
 skin
one held the 
 limb and the other immersed the 6 inches p.o.p roll in luke warm water until all air bubbles 
 within the bandage had disappeared .
then the p.o.p roll was removed from the water and 
 squeezed gently to expel excess water .
the wet roll was then applied around the limb with 
 gentle firmness , while the assistant maintained the knee in maximum possible extension . 

while the plaster was wet the physiotherapist smoothed it and molded it to conform to the 
 contours of the limb .
this process was repeated on a further 8 occasions at intervals of 23 
 days .
special care was taken to maintain gained rom while checking the skin for breakdown or 
 sores .
measurements were taken by orthotist for knee ankle foot orthosis ( kafo ) with a hip 
 attachment . during this period
all processes 
 were performed by pediatric physiotherapists and each casting process took around 30 minutes 
 for each limb .
arrangements were made with orthotist and the child was fitted with kafo and 
 hip support days after cast removal . following the kafo fitting , the child received 
 intensive physiotherapy including gait training .
gait training began in parallel bars for 
 three weeks with the locked knee kafo attached to the hip and was followed by walking 
 outside the parallel bars using a brace and reverse walker for about 2 months .
knee flexion contracture was measured in 
 degrees before applying the serial casts and immediately after cast removal .
the knee flexion contracture , which was not corrected with passive stretching , improved 
 with casting from 40 knee extension to 5. at one year follow - up , the child continue to 
 ambulate independently for short distances ( home and school ) with an unlocked kafo and 
 forearm crutches .
this case report shows that using serial casting and follow - up with bracing may be a useful 
 intervention for a young spina bifida child with knee flexion contracture .
one possible 
 explanation for the knee flexion contracture presented in this child , was that in addition 
 to muscle imbalance there was delayed physical therapy intervention as treatment started 
 after 4  years of age .
the result in the current case study was consistent with those studies 
 which have examined the effectiveness of serial casting in the management of joint 
 contracture3 , 10 , 11 . in these studies , the 
 improvements translated into reduced spasticity and
improved rom , but whether the 
 improvement of rom resulted in function improvement was not clear . in this case report , 
 immediately after cast removal and at one year follow - up , the gain in rom directly 
 translated into improvement in mobility function .
however , in this case report gain in joint 
 range was maintained at one year after cast removal .
a possible explanation for the rom gain 
 and improvement in mobility function after one year may be the arrangements which were made 
 in advance with orthotist , and the intensive gait training and direct supervision provided 
 by physical therapists .
fear of skin breakdown in serial casting to correct joint contracture in children with 
 sensory loss may be behind the limited use of serial casting trials in this patient group . 
 in this case report
careful measure such as padding well and changing the cast in a short 
 period of time may have contributed substantially to the improvement in joint rom without 
 skin breakdown or any other complications . to date , this case report is the first to report 
 using serial casting for children with sensory loss without complications .
another advantage 
 of using the serial casting approach is that avoided surgical intervention . despite the fact 
 that , surgical intervention is the most effective choice for correction of joint 
 deformities
, there is great potential risk of complications , arising from anesthesia and the 
 varying skills of surgeons12 . in 
 addition
, surgical intervention requires a long waiting time for an appointment at public 
 hospitals and if done in a private hospital it is very expensive .
other recognized 
 complications of surgical intervention of knee flexion contractures in children with spina 
 bifida include over lengthening , infection and scarring1 . the child s parents were extremely pleased when they noticed that knee joint rom had 
 improved without complications and at a later stage when they saw their child could stand 
 and walk .
correll and gabler13 reported that musculoskeletal deformities 
 are one of the main factors influencing ambulation in children with spina bifida . on the 
 other hand , children who stand or walk early in life ,
even if they become non - walkers later , 
 will be more independent in their homes , have a lower incidence of medical complications , 
 fewer fractures and greater independence compared to non - walkers14 .
the outcome of this study should be treated with caution 
 because only one case study is presented .
further research is needed to determine the 
 effectiveness of using serial casting with larger samples including children with various 
 levels of spina bifida .
   [ purpose ] the purpose of this case report is to describe for the first time , the use of 
 serial casting in the management of knee joint flexion contracture for a young child with 
 spina bifida . 
 [ case description ] the child was 6  years old , and had l3l4 spina bifida 
 level lesion with quadriceps muscle strength grade 3 + . 
 the child had previously received 
 weekly physiotherapy including stretching for knee flexion contracture on both lower 
 limbs , but without improvement . 
 [ results ] the knee flexion contracture , which was not 
 corrected with passive stretching , improved with casting from 40 knee extension to 5 
 knee extension as measured by a standard goniometer over a period of 4 weeks . 
 careful 
 measures were taken to ensure skin integrity . at 
 follow up after one - year , the child could 
 ambulate independently with the help of walking aids . 
 [ conclusion ] the outcome indicates 
 that using serial casting and follow - up with the use of bracing may be useful for 
 enhancing the walking ability of a young child with spina bifida with knee flexion 
 contractures . 
 further investigations of serial casting as well as investigation of serial 
 casting with other interventions are warranted . 
INTRODUCTION
SUBJECT AND METHODS
RESULTS
DISCUSSION