Providing a stable base of support: An exploration of orthotics in children with Down Syndrome
Hello, my name is Julie Johnson. I am a pediatric rehabilitation physician in South Dakota in the United States. Thank you very much for inviting me to talk about one of my passions, which is using orthotics to help promote functional abilities Today ,we will talk about several things. First, we will discuss what we know about children with Down syndrome in relation to their muscles and ligaments, motor development, and foot and ankle alignment. Secondly we will talk about several different types of orthotics that can help correct abnormal alignment in the foot and ankle. I will also suggest which children might benefit from these types of orthotics.
Lastly, we’ll review what information is available in the recent literature regarding using orthotics in children with Down syndrome or low muscle tone As a general disclaimer, I will talk about several brands of orthotics. I don’t have any affiliations of any kind with the orthotic companies that I will be discussing today The common definition of an expert is a person who has a comprehensive and authoritative knowledge or skill in a particular area. The definition that we will be using today for an expert, is a person from out-of-town with a PowerPoint presentation. This gives me the opportunity to be an expert! As I said earlier, I am a rehabilitation physician who particularly specializes in pediatrics. I have been working in the rehabilitation field since 1992. In my daily work I work closely with several individuals including my patent and their family, orthotists who make braces, physical therapist as well as other therapists.
My goal is to provide the best possible care for children in order to promote their functional abilities What do we know about Down syndrome that helps us better understand standing stability for children with this diagnosis?: Some of what we cover will be a review from what Dr.s Poppi and Cerney discussed earlier in their talks So as we all now know, children with Down syndrome have low muscle tone and ligamentous laxity. This leads to hypermobility or excessive movement at their joints. In addition, the muscles are weak and need to be strengthened.
We see in young children that they have delays in achieving their gross motor milestones. As Dr. Cerney discussed, we also know that children with Down syndrome may have difficulty integrating sensory information.
Young children also have decreased overall balance. We also know that almost all children with Down syndrome walk. If that is the case, why do we need to use orthotics Why use orthotics to improve standing stability?: In the following several slides, I will explain to you why I think orthotics are important to use in children with Down syndrome One of the primary goals of orthotics is to provide foot and ankle support to correct the malalignment that is caused by the ligamentous laxity and the lower muscle tone that the children with Down syndrome have. When we look at the foot in standing, we notice that there is a loss of the arch of the foot. We call this pronation. We also see that there is a tipping of the heel and this is known in medical terms as hindfoot valgus or eversion. When we look at the front of the foot we see that the foot tends to turn out and this is called forefoot abduction This is an example of the changes that we see in the foot.
You can see that the heel is tilted, the front of the foot is turned out. It’s difficult to see that there is a loss of the arch in this specific picture When we use an orthotic, the orthotic provides a stable base and corrects the alignment issues that we saw in the last slide. When this alignment is improved, there is a more even pressure distribution for the foot and overall a more stable base of support for the foot. This helps the child to function in standing and then walking When the alignment is improved, and there is more stability, we then see changes in the child’s gait or walking. There is a more narrow base of support and the feet are closer together with walking. The toes do not point out as much.
They point more directly forward. We also see an increase in balance and overall stability Additional goals for using orthotics include providing support and control of the foot and ankle while the child is growing and developing. Lastly, we use orthotics to prevent” bad habits” and other compensatory strategies that the child will use if their foot is not in a well aligned position This is an example of feet of an older child. You can again see significant tilting of the heel.
In this picture we can see that there is a complete loss of the arch of the foot. The child is bearing weight on bones that are usually suspended in the arch and are not meant for weightbearing. An orthotic would be helpful in this instance Which orthotic options exist?: Now lets talk about the different types of orthotics that exist to help support the foot and ankle These are the most common types of orthotics. The foot orthotic is also abbreviated an F0. This simply supports the foot from the bottom. The UCBL which stands for the University of California biomechanical laboratory where it was designed ,is higher than a foot orthotic.
It comes up farther along the sides of the heel and thus provides more support. The SMO or supra malleolar orthotic provides even more support. The malleoli are your ankle bones on either side of your ankle. This orthotic comes up above the ankle bones and provides higher levels of support Although we would like to have specific guidelines about which orthotics to use for which child, as of yet, these do not exist. There are, however, general principles that help us to choose. The foot orthotic and UCBL are typically used in children with less ligamentous laxity or malalignment, children who are lighter in weight and shorter. These 2 types of orthotics provide less support than the SMO, and thus are typically used when children have “milder” alignment and laxity issues.
The supramalleolar orthotic, which provides more support, is typically used in children who have more laxity or more alignment difficulties. It can also be used in children who are little bit heavier and taller Now let see what these look like. These are pictures of foot orthotics. These orthotics are made by the cascade orthotic company. Cascade does have suppliers in the region here, thus would be an option for getting orthotics. Let me say, that there are many companies that make orthotics, and the physician or therapist that you work with may well have a provider that they choose to work with. They can help you to decide how to get the best orthotics for your child. The picture on the left shows a custom made orthotic.
The picture on the right shows what we call a prefabricated orthotic which is made ahead of time and is sized to the child based on some measurements. I must say, that in my practice, I tend to used custom orthotics more often. Certainly, that is not always the case. These are the UCBL orthotics. You’ll notice that they have a higher trim line.
That means that they come up higher on the sides and hold onto the heel. These provide more support in the arch, and provide more support overall. The one on the left, is custom orthotic. This requires taking a cast or mold of the child’s foot The ones on the right are pre-fabricated and can be purchased by sizing to the child without any casting or molding necessary.. As you can probably tell by looking at the toe piece on all of the orthotics, this portion is very flexible. Each of these front ends of the orthotics will flex and bend so that the child can get up on her toes and can push off and run in them. We do not want a rigid foot plate on the bottom of the orthotic. Similarly, the foot orthotics as shown in the previous slide are also flexible at the toes As you can see, as we are going up higher the orthotics look like they will provide more support.
These are examples of the SMO or supramalleolar orthotic.s The one on the left is a pre-fabricated orthotic which again can be taken by measurements of the child’s foot. The one on the right is a customized orthotic. For this one, the child’s foot needs to be casted, and the cast is sent to the company and the orthotic is made for the child.
This allows several different color choices and options. Again note that the front part of this orthotic is flexible so that it bends at the toe. The primary support is provided throughout the support at the heel , arch,as well as across the ankle bones. There is padding inside here to provide comfort for the ankle bones. This plastic is very flexible This is another type of SMO from another company.
The company is called Sure Step. These are also ordered by measuring and sizing of the child’s foot. The pictures on the right show the child’s foot positioning without the orthotics on and then in the orthotics. Again, the the plastic is very flexible.
The SureStep orthotics do not come all the way out to the toe like the other ones do. I would like to stress and highlight that orthotic needs typically change as children grow. Children may require a lot of support initially such as an SMO orthotic. As they get stronger and become less lax overall, they may need less support and may be able to go down to something such as the UCBL or maybe even a foot orthotic.
On the other hand, some children who are less lax in their ligaments with less malalignment, may start out in something more like a foot orthotic, but as they become bigger and heavier may need more support. In any event, children change as they grow and we need to keep an eye on these things. As children outgrow their orthotics, I typically reevaluate and decide what do they need now? What does the research say about use of orthotics for children with Down syndrome?: now we’ll take a look at the research literature In an article by Silverstein, Hillstrom, and Palisano , the effect of foot orthotics was assessed on the standing foot posture and gait in young children with Down syndrome. Their Conclusion was that custom foot orthotics improvde the heel position, out toeing, and decreased gait variability in children with Down syndrome. As you’ll notice, this was a small study of 16 children within a limited age range; children 3-6 years of age. Another study by Martin looked at the effects of the SMO orthotic on postural stability. Again, a small study of 17 children with a limited age range.
The conclusion was that the flexible SMO did have a positive impact on postural stability. In another small study of 6 children aged 4-7, Looper,, Benjamin, Nolan, and Schumm tried to define what measurements needed to be taken when determining which child should be fit with which type of orthotic. The study concluded that of all the measurements assessed, no specific recommendations could be made. It did however, suggest a correlation between hypermobility, leg length and weight with the type of orthotic prescription In a larger study of 99 children aged 6-11, the authors discussed walking or gait in children with Down syndrome.
The authors concluded that children with flatfoot displayed a less functional gait pattern in terms of how the ankle moves than children without flat foot. This suggested that the presence of a flatfoot leads to less functional walking skills. In summary, research is lacking in the area of orthotics and their function in children with Down syndrome. As you can see, sample sizes are typically small with variable age ranges.
As with most everything in the rehabilitation world, more research is needed to provide definitive answers. For now, we use our clinical experience combined with our limited research to make best choices for children regarding orthtoics In summary then, we know that children with Down syndrome have low muscle tone, ligamentous laxity and muscle weakness. This leads to malalignment of the foot and ankle. Additionally, we know that orthotics stabilize the foot and ankle and this helps with overall balance and walking The goal of using orthotics is to prevent bad habits or compensatory techniques in the long run. These can develop if the foot and ankle are not stable. These changes occur while the child is growing and getting stronger if the foot and ankle are not supported.
Lastly, as children grow and develop their orthotic needs change, thus we need to continue to reassess.
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