Case Study | Testing the JumpStart Kangaroo for High Muscle Tone Applications

Here at Cascade Dafo, it is common to push the envelope and continually question why something cannot be done. For instance, although the JumpStart line of products was originally developed for the early-intervention, low-tone patient group, we are field-testing the brace to fi nd out how far it can go to serve high tone patients.

I’d like to share a story with you from this testing. For the past two years, we have been working with a very sweet young girl who is now three years old. She has a diagnosis of cerebral palsy and presents with pronation and high muscle tone. Suzanna (not her real name) did so little weight bearing when we first met her that the shape of her heels appeared under-developed (Fig. 1). We wanted to keep her in a position of slight dorsiflexion (DF) in order to meet our main goals: to prevent a loss of range of motion at the ankles and to help her stabilize in a reasonable position for standing and beginning walking. Without a full, rounded hindfoot to hold on to, the brace would have a challenge keeping her heels down and back, especially when combined with episodes of rigid high tone.

Since Suzanna had no previous orthotic experience, we thought a gentle starting point was in order. We measured her for a JumpStart and delivered a combo (the Leap Frog and the Kangaroo inner shells plus one pair of base pieces). Toe rise pads and instep pads helped with positioning and comfort.

Although there was some success, Suzanna wasn’t making the kind of progress in heel control and PF block that her PT had hoped for. The PT requested a custom hinged DAFO 2 (hinged PF block, DF free). We delivered it and quickly ran into trouble. In spite of a good fit and excellent support from both her PT and her devoted mother, Suzanna pulled her heels up and out of the brace on a regular basis. Because she was then mis-positioned in the orthosis, she had trouble with redness and discomfort. Even after we adjusted, discussed donning technique, and redid the brace, the result remained the same. Suzanna’s soft, baby-like skin would not tolerate this much longer.

Though the DAFO 2 did block PF well, Suzanna’s mom had remarked that they found the DAFO 2 difficult to live with. She wanted to know whether we could make the JumpStart more effective for her daughter. Meanwhile, the JumpStart Kangaroo had continued to evolve and now featured a greater (3.5-degree) DF angle, flared posterior, higher instep trimline and taller height. We decided to give it another try.

In fact, we have tried it several times now. We experimented with alternative strapping arrangements and with cutting away some of the instep trimline to allow the strap to pull in closer to the ankle. We were looking for a better way to keep her down and back in the brace in order to keep her heel seated. Our thought was that more direct downward (forefoot strap) and backward (possible distal tibia strap) pulling might be better than a single 45-degree instep strap angle, and the three together might be even better (Figs. 2 and 3). In addition, an instep pad with a thickened center could provide more diagonal pressure. Because her episodes of high tone are less likely when positioned at a greater DF angle, we also tipped her forward another degree or two by adding a ¼-in. foam shim to the proximal edge.

At Suzanna’s most recent fitting, we were encouraged by what we saw (Fig. 4). She stood playing at a table with the JumpStart Kangaroos on. Not only were her heels fully on the floor, but she also voluntarily moved into more DF when reaching for a toy.

Good news in the research and development of our products translates quickly to good news for all of our customers. If this experiment proves successful over time, it will become yet another new option. And we’ll be grateful once again for the patient who asks us why it can’t do more. Thank you, Suzanna.

-- Loretta Sheldon, ROA

Loretta Sheldon is an ABC Registered Orthotic Assistant and a member of Cascade’s management team. She has been with Cascade since 1998.

Fig. 1. Suzanna's usual plantarflexed position. Fig 2. The improved JumpStart Kangaroo. In addition to the now standard 3.5-degree DF angle, flared posterior, higher instep trimline and taller height, this one features a distal tibia strap. Fig. 3. Done checks fit on Suzanna's JumpStart Kangaroo. Fig. 4. Suzanna bearing weight in her new JumpStart Kangaroo. In it, she achieves better DF.