Serial Casting in the Upper Extremity of Children with Cerebral Palsy

Keeping Current © Julia Lockhart, Karen Margallo, & Dianne Russell, 2010


Serial casting is an intervention practice that is becoming more commonly used in occupational therapy (OT) practice, in addition to other treatment modalities/protocols for children with cerebral palsy to manage spasticity and related contractures. Research on serial casting has primarily focused on the lower extremity with results indicating significant improvement. These concepts are now being applied to the upper extremity, however there is limited current research with respects to serial casting in the upper extremity.

Past systematic reviews have looked at upper extremity positioning/casting from a general perspective, with no delineation between studies looking at the effectiveness of positioning devices designed to increase range of motion (i.e., serial casting) versus reduction of tone (i.e., inhibitive casting) versus maintenance of range (i.e., static splinting). Autti-Rämö et al (2006) summarized the evidence from various systematic reviews pertaining to upper and lower limb casting and orthoses in children with cerebral palsy, and concluded that the effectiveness of upper extremity casting or splinting was inconclusive and further research is required. Lannin et al (2007) systematically reviewed all upper extremity casting studies in individuals with central nervous system disorders, and determined that there was no evidence to support or refute the effectiveness of upper extremity casting. There have been no systematic reviews that have looked specifically at upper extremity serial casting.

The purpose of this overview is to summarize the evidence of the effectiveness of upper extremity serial casting in managing contractures in children with cerebral palsy (CP).

Review Methodology

A literature search was completed using the Cumulative Index to Nursing & Allied Health Literature (CINAHL), 1982 to November Week 2 2008, and Ovid Medline (R) In-Process & Other Non-Indexed Citations, 1950 to November Week 1 2008. There was an additional search of existing systematic reviews using all EBM Reviews - Cochrane Database of Systematic Reviews (DSR), ACP Journal Club, Database of Abstracts of Reviews of Effects (DARE), and Cochrane Central Register of Controlled Trials (CCTR). Key words included: upper extremity, upper limb, casting, serial casting, spasticity, and cerebral palsy.

What is the difference between Inhibitive Casting and Serial Casting?

Inhibitive casting differs from serial casting in that only a single static cast is used and the purpose is to reduce tone rather than lengthen muscle, thereby improving function. There has been some research on the use of single static inhibitive casts to reduce spasticity in a muscle group or muscle groups. Harthun Smith & Harris (1985), Cruickshank & O'Neill (1990) and Law et al (1991) all reported improved hand function after casting. Tona & Schneck (1993) completed a case study looking at the efficacy of an upper extremity cast worn for 48 hours and found a temporary decrease in spasticity. By reducing wrist flexor tone through inhibitive casting, it allowed for active strengthening of the wrist extensors, and resultant increased wrist stability for grasp and release activities.

Serial casting is defined as the use of a series of progressive casts to increase muscle length using low load prolonged stress to contracted tissues (Tardieu & Tardieu, 1987; Ada & Canning, 1990; O'Dwyer, Neilson & Nash, 1994; Preissner, 2001; Flett, 2003). The casts are replaced at intervals, allowing the tissue to respond to increasing lengthened positions.

How does Serial Casting work?

Serial casting is based on the premise that shortened muscles maintain the plasticity for lengthening. Providing a prolonged stretch offers biomechanical benefits and inhibits spasticity. Childers et al. (1999) looked at motor neuron activity in a spastic upper limb and found that the level of activity was decreased when a cast was applied. Biomechanically, the prolonged stretch leads to increased muscle fibre and tension length through an increase in the number of serial sarcomeres (Preissner, 2001). Using this maintained low load stretch, the muscle tissue unfolds and there is a temporary re-alignment of the collagen fibers within the connective tissues, which stimulates growth of the muscle (Tardieu & Tardieu, 1987; Ada & Canning, 1990; O'Dywer, Neilson & Nash, 1994). In muscles with increased tone, the shortening of muscles and connective tissues recurs unless the muscle length and stretch is maintained (Wilton, 2003).

What do we know about Serial Casting in the Lower Extremity?

While serial casting is a relatively new modality in upper extremity spasticity management, it has been used in addressing contractures in the lower extremity for many years. Contractures of the hip, knee and ankle all result in gait dysfunction; serial casting was first introduced as a conservative method of managing contractures, thereby delaying the need for surgery. It has become an increasingly integral part of treatment for children with CP (Glanzman, 2004), and there have been numerous studies supporting its effectiveness in lower extremity spasticity management. Several studies have demonstrated an improvement following serial casting of the gastrocnemius in children with CP, including an increase in active and passive dorsiflexion range of motion, a decrease in the resistance to passive stretch, changes in quality of gait, increase in speed and a decrease in energy expenditure (Brouwer et. al, 1998; Cameron & Drummond, 1998; Kay et al, 2004; Cottalorda et al, 2000; Brouwer et al; 2000).

What are the effects of Serial Casting in the upper extremity of children with CP?

There have been only a few studies that have focused on serial casting in the upper extremity of children with CP, and the effect on range of movement in specific joints. King (1982) applied six casts to a patient with severe elbow spasticity and resultant contracture, and noted significant gains in active and passive extension. Yasukawa & Hill (1988) reported similar results after serial casting the elbow and wrist of a child with CP. Copley et al (1996) applied a series of casts to children with CP, with resultant substantial gains in active and/or passive range of movement. These results supported earlier findings reported by Kitson (1988) and Steer (1989). Yasukawa et al (2003) applied four elbow casts with successive gains in range of motion; however these gains were temporary unless followed by a definitive orthotic device to maintain range. Yasukawa et al (2008) examined the use of serial casting to obtain gains of 15-20° in passive range, followed by the use of a custom orthosis. In all six subjects the serial casting was successful in gaining the required passive range, however maintaining range using the orthosis was dependent on wearing compliance.

What are the protocols for Serial Casting in the Upper Extremity?

Several studies have outlined protocols for upper extremity serial casting (King, 1982; Yakusawa & Hill, 1988, Yakusawa, 1990, Copley et al, 1996, and Yakusawa et al, 2003, Yakusawa et al, 2008) however there are variations in joint application, length between re-castings, number of cast applications, and casting material. King (1982) applied a series of plaster casts in a position of maximum range. When 20° of passive range was obtained beyond the position of the cast, a new cast was fabricated. Once an angle of 15° from normal range was reached, casting was stopped and a final splint made for maintaining range. Yakusawa (1990) described a casting protocol involving application of a cast in the most comfortable position (i.e., sub-maximal range) in order to provide a mild, tolerable stretch, and prevent micro-tearing of the soft tissue. The casting program lasted four weeks and a new cast was applied once a week. Flett (2003) indicated that serial casting typically involves cast application that is maintained for five to seven days, removed and immediately replaced with another cast at an increased angle within available range of movement. Casting and re-casting occur over a period of two to three weeks. In studies by Yasakawa et al. (2003, 2008), casts were worn for seven to ten days with each successive cast incorporating gains in range of motion obtained from the previous cast. Again, once maximal range was reached, a maintenance orthosis was fitted. The protocol for upper extremity casting outlined by Yakusawa & Hill (1988) involved re-casting until full range or no further gains were achieved. In a study by Copley et al (1996), the cast and re-cast schedule was set at once per week as this was what could be most easily managed within the context of their setting. Preissner (2001) reviewed the use of plaster versus fiberglass casts. Plaster casts are heavier but also provide more proprioceptive input; whereas fiberglass casts are more lightweight, can be easily made into a removable bivalve cast, but also breakdown easier than plaster.

What are the implications and future directions of Serial Casting in Occupational Therapy practice?

The current research suggests that serial casting may be an effective modality for lengthening muscles affected by spasticity in children with CP. Although this paper focuses on children with CP, the practice of serial casting has been applied to other pediatric diagnoses and conditions such as acquired brain injury, brachial plexus, and burns (Basciani & Intiso, 2006; Ahmed et al., 2006; Pohl et al., 2002; Ridgway et al., 1991; Bennett et al., 1989).

More research is warranted to explore the effectiveness of serial casting and its long term impacts. In addition, research should examine the impact of adjunct spasticity management therapies including Botulinum Toxin A and oral medications; single joint vs. multi-joint casting (i.e., elbow & wrist); and the effectiveness of follow-up interventions (e.g., splinting, therapy) to maintain range of movement. When evaluating the effectiveness and long-term effects, further consideration should be given to the selection of outcome measures that encompass all dimensions including impairment, activity, and participation.


The literature on serial casting of the upper extremity in children with CP has been limited to date. There has been considerable focus on serial casting in the lower extremity, with early research indicating that similar results can be obtained in the upper extremity. While the upper extremity findings have been positive, further exploration is needed to expand the use of serial casting in clinical practice.

Update written by:

Julia Lockhart, M.Ed., OT Reg. (Ont), Children's Developmental Rehabilitation Programme (CDRP), McMaster Children's Hospital, Hamilton, ON; associate professor, McMaster University School of Rehabilitation

Karen Margallo, M.Cl.Sc. OT, OT Reg. (Ont.), Children's Developmental Rehabilitation Programme (CDRP), McMaster Children's Hospital, Hamilton, ON; professional associate, McMaster University School of Rehabilitation

With support from Dianne Russell, PhD, CanChild Centre for Childhood Disability Research, Hamilton, ON

Want to know more about serial casting in the upper extremity?

Contact: Julia Lockhart,

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