Thoughts from Don | The Bracing Question: "Will My Child Benefit From Using Braces?"

The scenes in the movie Forrest Gump, showing a child growing up in the 1950s with his legs caged in by clunky metal, are a common reference point for parents new to bracing. This is a treatment they would not care to take on. It’s natural for parents to question the need—“Will my child benefit from using braces?”

Over years of working with children, parents and physical therapists, I have refined my answers to encourage a pragmatic grasp of what challenges bracing can help. Here are some thoughts that might help you give the parents of your patients a more realistic perspective. Though parents may trust your opinion implicitly, they want a way to think about the issue that they can see evidence of and discuss rationally. The question then expands into a series of questions.

Should my child wear a brace at all?

In answering this, the type and magnitude of the motor skill delay the PT has assessed is useful. Generally, a PT evaluates a child’s sensory-motor skills with a multi-level approach, considering development, neurological organization for movement, sensory processing and the ability to acquire skills.
There can, however, be social stigma connected with wearing a brace. Parents may fear taunts by other children, rude stares and so on. If you sense this is an issue with a particular set of parents, keep it in mind as you select a brace style. A less obtrusive brace style is more likely to be worn than a high-profile one that may attract unwelcome notice, and it may be an acceptable choice as long as it does at least some good. And if a child is often in an environment with other children who wear braces, brace wear may not seem like a big issue. This is especially true for very young children.

Which brace is right?

Parents don’t need to know the biomechanical techniques used to derive an effect; they just need to know the problem that is being solved. Presenting choices to parents in a way that describes the gait dysfunctions they address gives the parents less of a cognitive burden in considering options.

Will my child be dependent on braces for the long term?

Since the atypical movement patterns we see can result from such a wide range of conditions (and, in some cases, combinations of conditions), it’s not realistic to make a categorical prediction at the outset of treatment.
However, if, given the diagnosis, it is possible for a child to develop better voluntary control, then our orthoses will help develop his or her potential for improved movement. Our goal is not just to support a child’s foot, but to guide it towards correction. We do see improvement on a regular basis. The key to graduated lowering of support is to have options available for a smooth transition to the next level down.

General physical therapy concerns

The function of a child’s foot and gait must be considered in the context of not simply bracing, but in a larger holistic integration of the entire sensory-motor skills system. The bracing solution must support the PT’s goals to accelerate motor development as well as the orthotist’s concerns about the role of a more functional foot position, appropriate device and level of stability. (It’s highly beneficial for a patient to receive the combined efforts of a team of professionals: a physician, a physical therapist and an orthotist, for instance.) For example, PTs are often motivated to seek a bracing solution because they are concerned that the patient’s poor foot position will make it hard to develop foot-knee-hip-trunk control.

Other global considerations—type of dysfunction, family and home life (including the level of home support expected), school situation and attitudes of the individual patient, for example—can carry a great deal of weight.

To help parents understand what needs to be corrected in their child’s gait, it’s useful to have a practical explanation of how gait normally develops.

Children may not have a “typical” gait until 6 or 7 years of age. Sit-to-stand, in particular, can happen in unusual ways. The typical baby’s foot presents a pronated appearance, with an abundance of soft tissue and flat feet. Children don’t start out with good foot position, but they normally find it fast if their sensory-motor skills are functioning properly. For every child, an important part of foot position development is experimentation.However, if a PT asks us to support the foot position of a very young child, it is usually because of a bigger motor developmental delay: gait challenges are anticipated as part of a larger, known condition. An example is the case of, say, a 2-year-old who is pronated and has extreme extensor tone, preventing even a standing position. This represents a delay of at least a full year. In this case, foot position is deemed crucial, since he can’t begin standing (or progress developmentally in his gait) until his foot and ankle are corrected. Pronation in a typically-developing 2-year-old is not as critical.

My basic approach to bracing has three parts.

• Best position of function
  By this I mean a relatively balanced, neutral, typical position, neither pronated nor supinated. We attempt to bring the foot into this position: heel vertical, forefoot horizontal, ankle angled slightly forward (in about 3 degrees of dorsiflexion). This neutral position, in my view, is both the best position for weight bearing and the best position for the “swing phase” of the gait. Our overarching goal is to provide the least amount of support that will achieve the best position of function.
• Learn movement by moving
  In order to learn good movement, the foot needs to be able to move repeatedly. A child who lacks the skills to recruit voluntary control, if left untreated, never experiences the repeated success that normal movement provides. A brace that allows some movement while serving as a “training aid” towards typical gait is the clear path to eventually diminishing orthotic support. Choosing a brace that will allow movement where the child’s gait is functional—starting with what they do right—is a highly effective alternative to more restrictive bracing.
• Least amount of support
  Rather than brace heavily, we want the foot to experience as much useful movement as possible. We want the child to explore foot position in a guided range: think of guard rails on a highway, with the freedom to move ahead but with protection from danger. For this to happen, we make braces with as much flexibility as possible along the axes where the child has good foot control, providing support (for pronation/supination, DF/PF, eversion/inversion) where the child needs it.

Patient presentations and solutions

Patients come to us with a wide range of skills, needs and developmental levels. They require a correspondingly wide range of choices. Functionally, our solutions range from simple shoe inserts to ankle foot orthoses that provide strong support. As a tool to use patient presentation to select a brace, we have developed seven patient presentations, or groupings. Since we believe that early bracing can reinforce good foot position and prevent bad habits from becoming ingrained, we have created a sort of microcosm of patient groups and solutions for the pediatric population. The presentation types relevant to early pediatric groups (birth to three years old) include:

• low tone pronation—due to weakness or lack of integrated muscle control of the feet; usually easily correctible.
• high tone pronation-supination—due to high muscle tone in lower extremities; resist correction.
• inconsistent ankle modulation—foot position and movement unsteady, erratic or unstable.
• excessive plantarflexion—toe walking: absent or delayed heel contact during gait; often due to high muscle tone or sensory issues and may be idiopathic.
• knee hyperextension—caused by weakness or high tone.

Additional groups into which a patient may fall include crouching and positioning/limited ambulation. Once we have determined what presentation group a child fits into, we examine the set of braces available as choices for each presentation. As a child’s skills improve, it’s also important to have available a corresponding bracing path of diminishing support.

-- Don Buethorn

Don Buethorn, CPO, is founder-owner of Cascade Dafo, Inc., and Cascade Prosthetics and Orthotics.