TIP OF THE MONTH: October/November 2013
Serial Casting After Botox®
Third-Place Winning Article, 2013 Paper of the Year Competition

by Jacob Lookabill, OTC

Wake Forest Baptist Medical Center’s Pediatric Orthopedic department often uses Botox® (botulism toxin) as a way to treat patients with spastic conditions. Botox® is used to paralyze the muscles and nerve endings. This is usually a multi-stick procedure and takes about twenty-four hours to take full effect. These injections are given in a couple of different ways. Doctor Koman was the first physician to use Botox® to treat upper-extremity spasticity in cerebral palsy patients. In some cases, Doctor Koman uses Emla cream, a product that numbs injection sites. Most patients still complain of a highly intense sting and do not like receiving the injections. Once he has completed the injections the patient is sent to a casting room for serial casting.

During the casting process the patient is placed in the prone position with the knee flexed to 90 degrees, which allows maximum stretch. In most cases this should be a team casting procedure. The first tech gets the stretch and watches the position while the other tech applies the cast. Both techs should always be watching for proper position of the foot while setting up the cast. When building a stretching cast, a toe plate is always applied to provide both patient comfort and protection of the forefoot.

Doctor Kolaski, a Wake Forest Assistant Professor, currently focuses her research on intrathecal baclofen, botulinum toxin, and pediatric traumatic brain injuries. Doctor Kolaski uses a sedation suite for her injections and uses an electrode stimulator needle to create muscle movement. This enables her to get accurate and precise injections. After the injections, the patient’s cast is applied in a supine position. Proper foot position is achieved due to less tone under the sedation. The team casting procedure is used to reassure proper foot position.

Brent Sapp, a leading Pediatric Physician Assistant, has several years of experience treating idiopathic toe walkers. In some cases he uses the serial casting approach for his patients. The same techniques are used for casting idiopathic toe walkers and Botox® patients. The length of time for casting depends on the response of the patients and often they may need to receive Botox® for the condition. However, in most cases getting coverage from insurance creates a problem.

Patients who receive serial casting, whether for Botox® or idiopathic toe walking, are evaluated seven to ten days after their procedure. During this visit the cast is removed, and the patient is checked for possible skin problems and range of motion. The back of the heel is always checked for blistering, as blistering may occur even with a perfect cast, due to the tone that some patients have. All boney prominences are checked, making sure they do not have any redness or skin irritation. If the patient has responded well to treatment, they are then fitted for an ankle foot orthosis (AFO) during this visit. Once fitted, they are placed back in a new cast with as much stretch that can be tolerated. There is usually about a five to 10 degree difference.

Botox® is used to treat spastic parts of the body, and in most cases this increases motor skills. Each patient is different, so responses can vary. Getting the most out of each injection by adding other treatments to the procedures, such as stretching techniques, splinting, and serial casting, is always a good idea. Patients need to be educated and know that Botox® is usually a temporary fix that only lasts three to 12 months. Some patients may still require surgery in the future.

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About the Author
Jacob Lookabill is a Certified Orthopaedic Technologist (OTC) at Wake Forest Baptist Medical Center in Winston Salem, NC. In 1999, he became the Orthopaedic Tech Supervisor in the adult and pediatric areas. He received his certification in July 2005. Most of his training has been at the level-one trauma center of Wake Forest, Giltech Total Contact casting in Baltimore, and the Carolinas Association classes. He is currently a member of the Carolinas Association of Orthopaedic Technologists and the National Association of Orthopaedic Technologists (NAOT). His overall vision is to develop state-of-the-art ways to care for and empower patients during their treatment.

Jacob’s paper, “Serial Casting After Botox®” was selected as the third place winner in the 2013 NAOT Paper of the Year Competition, sponsored by BSN medical. All articles submitted in the competition underwent a blind review by the NAOT Editorial Review Committee and were judged based on originality, timeliness, accuracy, and relevance to the profession of Orthopaedic Technology.