children with spina bifida develop a wide variety of congenital and acquired orthopedic 
 deformities including knee flexion contractures . knee flexion contractures in children with 
 spina bifida affect children s functional activities and interfere with the ability of 
 children to transfer and walk1 . a limited number of studies have looked at the management of knee flexion contractures in 
 children with spina bifida . surgical intervention is the most effective choice for 
 correcting joint contracture in children with spina bifida2 , 3 . however , with surgical 
 intervention there is a great potential risk of complications arising from anesthesia and 
 the varying skills of surgeons4 . serial 
 casting is the process of successfully applying and removing corrective plaster of paris 
 casts to increase extensibility in the soft tissues surrounding the casted joint5 . serial casting for improving range of 
 motion in the knee joint has been used in conditions such as cerebral vascular accident 
 ( cva ) , traumatic brain injury ( tbi ) and pediatric cerebral palsy6,7,8 . these previous studies show that serial casting can increase joint 
 range of motion , muscle extensibility , and improve functional mobility . however , to date , no 
 work has specifically looked at the use of serial casting in the management of children with 
 spina bifida , and there is a lack of documented evidence on the long term benefits of serial 
 casting apart from the evaluation at the time of the final cast removal . hence , the purpose 
 of this case report was to describe for the first time , the use of serial casting in the 
 management of knee joint flexion contracture in a young child with spina bifida , with 
 follow - up to document the long term benefit of serial casting after one year . the child was 6  years old with normal cognitive abilities , and had l3l4 spina bifida level 
 lesion with quadriceps muscle strength grade 3 + . the child was born through a normal 
 vaginal delivery and had normal developmental milestones . at 4  years old a clinical 
 examination revealed there was an associated history of neurological weakness , gait 
 abnormalities and urinary and bowel incontinence . neurological examination revealed reduced 
 sensation to pain and touch in the distribution of l3l4 nerves . the child was referred for 
 physical therapy intervention for the first time at 4  years old with lower limb joint 
 contractures including knee flexion contractures . physical therapy training included : manual 
 stretching exercise and prolonged stretch through strapping on a tilt table or application 
 of sandbag weights over the distal femur . physical therapy training was conducted in one 
 hourly session per week by a trained physical therapist but no improvement was seen . pre - intervention testing was completed one day prior to intervention which consisted of 
 standard goniometer measurement and was used to measure the childs knee joint ranges of 
 motion ( rom ) before and after casting over 4 weeks . the universal goniometer ( ie . the child s parents signed an informed consent statement that had been approved by the 
 al - hussein center ethical committee and al - hashmite university research committee board . the 
 child s legs were immobilized in a long cast from the thigh to the ankle ( fig . the serial casting technique applied in this study was modified to be appropriate for a 
 child with spina bifida . children with spina bifida are usually prone to decubitus ulcers 
 and other types of skin breakdown , especially on bony prominent areas10 . careful measures were taken to avoid bed sores or other 
 complications which may occur with casting . one of these measures included reduction of cast 
 interval changes ; the duration was reduced to two to three days . p.o.p is cheap , strong and radio translucent but the limb can not be 
 inspected . in order to avoid skin breakdown and friction between the cast and the child s 
 skin one held the 
 limb and the other immersed the 6 inches p.o.p roll in luke warm water until all air bubbles 
 within the bandage had disappeared . then the p.o.p roll was removed from the water and 
 squeezed gently to expel excess water . the wet roll was then applied around the limb with 
 gentle firmness , while the assistant maintained the knee in maximum possible extension . while the plaster was wet the physiotherapist smoothed it and molded it to conform to the 
 contours of the limb . this process was repeated on a further 8 occasions at intervals of 23 
 days . special care was taken to maintain gained rom while checking the skin for breakdown or 
 sores . measurements were taken by orthotist for knee ankle foot orthosis ( kafo ) with a hip 
 attachment . during this period all processes 
 were performed by pediatric physiotherapists and each casting process took around 30 minutes 
 for each limb . arrangements were made with orthotist and the child was fitted with kafo and 
 hip support days after cast removal . following the kafo fitting , the child received 
 intensive physiotherapy including gait training . gait training began in parallel bars for 
 three weeks with the locked knee kafo attached to the hip and was followed by walking 
 outside the parallel bars using a brace and reverse walker for about 2 months . knee flexion contracture was measured in 
 degrees before applying the serial casts and immediately after cast removal . the knee flexion contracture , which was not corrected with passive stretching , improved 
 with casting from 40 knee extension to 5. at one year follow - up , the child continue to 
 ambulate independently for short distances ( home and school ) with an unlocked kafo and 
 forearm crutches . this case report shows that using serial casting and follow - up with bracing may be a useful 
 intervention for a young spina bifida child with knee flexion contracture . one possible 
 explanation for the knee flexion contracture presented in this child , was that in addition 
 to muscle imbalance there was delayed physical therapy intervention as treatment started 
 after 4  years of age . the result in the current case study was consistent with those studies 
 which have examined the effectiveness of serial casting in the management of joint 
 contracture3 , 10 , 11 . in these studies , the 
 improvements translated into reduced spasticity and improved rom , but whether the 
 improvement of rom resulted in function improvement was not clear . in this case report , 
 immediately after cast removal and at one year follow - up , the gain in rom directly 
 translated into improvement in mobility function . however , in this case report gain in joint 
 range was maintained at one year after cast removal . a possible explanation for the rom gain 
 and improvement in mobility function after one year may be the arrangements which were made 
 in advance with orthotist , and the intensive gait training and direct supervision provided 
 by physical therapists . fear of skin breakdown in serial casting to correct joint contracture in children with 
 sensory loss may be behind the limited use of serial casting trials in this patient group . 
 in this case report careful measure such as padding well and changing the cast in a short 
 period of time may have contributed substantially to the improvement in joint rom without 
 skin breakdown or any other complications . to date , this case report is the first to report 
 using serial casting for children with sensory loss without complications . another advantage 
 of using the serial casting approach is that avoided surgical intervention . despite the fact 
 that , surgical intervention is the most effective choice for correction of joint 
 deformities , there is great potential risk of complications , arising from anesthesia and the 
 varying skills of surgeons12 . in 
 addition , surgical intervention requires a long waiting time for an appointment at public 
 hospitals and if done in a private hospital it is very expensive . other recognized 
 complications of surgical intervention of knee flexion contractures in children with spina 
 bifida include over lengthening , infection and scarring1 . the child s parents were extremely pleased when they noticed that knee joint rom had 
 improved without complications and at a later stage when they saw their child could stand 
 and walk . correll and gabler13 reported that musculoskeletal deformities 
 are one of the main factors influencing ambulation in children with spina bifida . on the 
 other hand , children who stand or walk early in life , even if they become non - walkers later , 
 will be more independent in their homes , have a lower incidence of medical complications , 
 fewer fractures and greater independence compared to non - walkers14 . the outcome of this study should be treated with caution 
 because only one case study is presented . further research is needed to determine the 
 effectiveness of using serial casting with larger samples including children with various 
 levels of spina bifida .