Thoughts from Don | JumpStarts and Fit

For very young children (age birth to three) with fully-correctible feet, JumpStarts are superb and my first choice. They offer distinct advantages in terms of compliance, effectiveness and affordability. For children aged four to seven with fully-correctible pronation, supination, inconsistent ankle, toe walking and knee hyperextension, JumpStarts are worth considering. My goal in this column is to dispel the notion that off-the-shelf-braces fail to offer the same level of quality as their custom counterparts.

Let’s consider the clinical decision-making process in the JumpStart context. Here are some relevant questions I seek answers to when evaluating bracing needs.

• Is this child a candidate for bracing?
• Is this child a candidate for a JumpStart?
• How well does the JumpStart fit and function for this child?

Bracing Candidate?

If a PT asks us to support the foot position of a young child, it is usually because gait challenges are anticipated as part of a larger, known condition. (For more on this, see "The Bracing Question" in the Spring/April 2008 Dafo Dynamics.) Intervening early with bracing can help the child develop toward typical gait without having to mitigate ingrained bad habits first.

JumpStart Candidate?

When we first started using JumpStarts, we saw them as solutions for fully-correctable low-tone pronation in very young children. JumpStarts certainly work well in that cohort, but at first we didn’t expect much application outside the smallest patients in this patent group.

Our JumpStart experience is characterized as two years of trial use, followed by more than a year of increasingly consistent clinical use. We have the advantage of extensive experience with JumpStarts (as well as close daily contact with those who make them). (We also take a JumpStart fitting kit with us; for more on these, see What’s News in this E-newsletter.) About a year and a half ago, we found application for other patient groups as well: fully-correctible supination, inconsistent ankle, toe walking and knee hyperextension. (Crouching remains a challenge that takes some creative problem solving in a JumpStart.)

Some specific conditions were well-handled by JumpStarts. We found JumpStart Kangaroos to be good tools for positioning and to correct clubfoot in small children. In children with inconsistent ankle modulation, the JumpStart Bunny can provide very good control in the swing phase.

At this time, I feel that, within the scope of our target early intervention patients (fully correctible, birth to 7), the JumpStart models we produce are the functional equivalents of their custom DAFO cousins.

In the clinical setting, some practitioners who have experience with custom DAFOs may be reluctant to consider JumpStarts as a solution. Yet casting is more difficult and less effective for small children. When one thinks of a difficult cast -- a squirmy kid or a blueberry muffin of a foot -- it’s not hard to imagine the anomalies that surface from the casting attempt.

Still, making the bridge to an off-the-shelf product is a challenge. Questions from clinicians tend to include: (1) can such thin plastic offer enough control? and (2) do these off-the-shelf products fit as well as custom braces?

Are Fit and Function Acceptable?

Let’s start with the thin plastic. I find it to be superior to more rigid bracing, since allowing some sensation of suppleness or "yielding" reduces the inclination of the patient to grip forcefully against any part of the brace. Because of its flexible design, we were able to be more aggressive with the contours of the JumpStart. The fluid pressure and volume of the foot itself within the orthosis contributes great stability and strength to the brace. Finally, the supportive nature of a shoe provides a stable outermost layer. (JumpStarts, like most custom DAFOs, are meant to be worn with socks and shoes.)

The question of fit is a good one, and it’s not trivial. Initially, we clinicians didn’t perceive the fit issue. We focused on function. After some solid field experience, I now find that if I have chosen the appropriate fit, the function is there. If a JumpStart isn’t functioning, it’s often because the fit is off. So what’s a surefire way to choose size?

1. First, get enough foot length in the brace for growth: ¼ to ½ in. of extra length in weight bearing, with socks on.
2. Then, choose enough volume for the patient’s hindfoot to sit well in the brace. (One tends to err on the side of not enough volume.)

The second part of sizing is the most difficult, since the flexible plastic tends to mask tightness. You can look for redness or discomfort around the heel or malleolus after a good period of wear; but a more immediate test is to look at the fit through just the inner liner. Expect to see that the heel can be seated in the brace when the patient is in dorsiflexion and there is gentle but consistent downward pressure on the knee. (Don’t expect the heel to seat itself.)

More important, the inner liner should fit comfortably around the malleolus and instep with a little spring or bounce when you push the instep trimline. If you squeeze gently and the foot is right up against the brace’s instep, the fit is too tight. If the brace is too small overall, you may also see a bowing out around the malleolus and dorsum. The contours of the brace should conform easily to the contours of the ankle, with no pinching when the shoe is on.

If the child is in a narrow and you see some tightness, try simply switching to a wide. (I use narrow sizes on only about one in five of my patients.) If you’re already in a wide, try going up a size or two in length for more volume. You can always trim the toe length shorter if needed.

Once you’ve fine-tuned fit, add the outer foundation and shoes and evaluate the function of the JumpStart. The clinical team decides together whether the solution answers all of the child’s mobility needs. The best way to do this is by evaluating against a plan that considers the whole spectrum of the child’s activities. Another useful strategy is to forecast what the child will need within the next half-year or so, based on developing ambulation or anticipated mobility changes.

If the fit’s off, you won’t see as good a functional improvement as if it’s right on, though the JumpStart is very forgiving of fit. A story can best illustrate the importance of fit. I had a patient with bad compliance; he hated wearing the JumpStarts (very unusual in itself) and had some redness after brace wear. His grandmother reported that, normally, when he came to therapy and saw the therapy dog (an enormous puppy the size of a table), he’d do a little skip -- a sort of spontaneous expression of exuberance. Wearing his new JumpStarts, though, he wasn’t doing the skip any more.

When I felt the brace around his instep and malleolus, it was quite tight. I simply shifted him to a wide, and the improvement in fit and function was dramatic, to say the least. Not only did he stop complaining, but he immediately did his skip. Such a remarkable improvement in attitude reinforces for me the importance of getting the fit just right.

With our warranty, you can order a JumpStart first, try it, and if it’s not right, exchange it for a different size or a custom DAFO. (Of course, if you choose a custom DAFO, we’ll need a cast.) If you read this column regularly, you know that I am not inclined to push products. I have seen such amazing JumpStart results with my own patients, though, that I’d like to see more kids benefit fully from wearing them.

-- Don Buethorn

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

Birth to three years old? Fully-correctible feet? It's a no brainer; think of JumpStarts first. Four to seven years old? Fully-correctible feet? Give a JumpStart brace full consideration. Young child but feet aren't fully correctible? You'll have to cast.

My Most Frequent Optimizations

When fitting a JumpStart, once I have settled on the right size and a style, these are the adjustments I am most likely to consider.

Toe Rise Pad

For higher tone, a toe rise pad can be a big help. It breaks up toe flexion nicely. If the flexion is very strong, consider the toe rise pad with hallux strap.

Super PF Block Strap

A new option for the JumpStart Kangaroo, a super PF block (heel seating) instep strap, follows a transverse strapping path to encourage the heel to stay down.

Instep Pad

My first choice is not to use an instep pad, because it adds a little bulk and the JumpStarts seem comfortable without it. But it can be useful for high-tone kiddos.

Height and Length Trim

Of course, the toe shelf of every brace, JumpStart or not, should be trimmed to give ¼ to ½ in. of growth room from where the child’s foot ends in weight bearing. In addition, I check the posterior height of the Kangaroos. The posterior should not be high enough to cut into the back of the child’s knees. Normally, if needed, I trim JumpStart Kangaroos in the field, using a heat gun and the edge of a desk or chair to flare out the trimline for best comfort.