Kelly A. Jeans

Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique.

BACKGROUND Currently, clubfoot is initially treated with nonoperative methods including the Ponseti cast technique and the French functional physical therapy program. Our goal was to evaluate the function of children treated with these techniques. METHODS We reviewed the cases of 182 patients with idiopathic clubfoot (273 feet) who were initially treated nonoperatively. Seventy-seven patients (119 feet) were excluded because they had either received a combination of nonoperative treatments or had undergone surgery prior to testing. Gait analysis was performed when the children were approximately two years of age. Temporal and kinematic data were classified as abnormal if they were more than one standard deviation from normal. RESULTS Gait analysis was performed on 105 patients (fifty-six treated with casts and forty-nine treated with physical therapy) with 154 involved feet (seventy-nine treated with casts and seventy-five treated with physical therapy). These patients were an average of two years and three months of age, and their initial Diméglio scores ranged between 10 and 17. No significant differences in cadence parameters were found between the two groups. The rate of normal kinematic ankle motion in the sagittal plane was higher in the group treated with physical therapy (65% of the feet) than it was in the group treated with the Ponseti cast technique (47%) (p = 0.0317). More children treated with physical therapy walked with knee hyperextension (37% of the feet) (p < 0.0001), an equinus gait (15%) (p = 0.0051), and footdrop (19%) (p = 0.0072); only one patient treated with casts walked with an equinus gait, and only three demonstrated footdrop. In contrast, more of the patients in the cast-treatment group demonstrated excessive stance-phase dorsiflexion (48% of the feet) (p < 0.0001) and a calcaneus gait (10%). More feet in the physical therapy group had an increased internal foot progression angle (44% compared with 24% in the cast-treatment group; p = 0.0144) and increased shank-based foot rotation (73% compared with 57% in the cast-treatment group; p = 0.05). CONCLUSIONS While the rate of normal kinematic ankle motion in the sagittal plane was 65% in the group treated with physical therapy, the gait abnormalities that were seen in that group were characterized by mild equinus and/or footdrop. The rate of normal kinematic ankle motion in the sagittal plane was 47% in the cast-treatment group, but the most common gait abnormality in this group was mildly increased dorsiflexion in the stance phase. The rates of calcaneus gait and equinus gait were <or=15% in each nonoperative group. The differences between the physical therapy and cast-treatment groups may, in part, be the result of the percutaneous Achilles tendon lengthening that is performed as part of the Ponseti cast technique but not as part of the physical therapy program.

Plantar Pressures Following Ponseti and French Physiotherapy Methods for Clubfoot

Background Recent trends have led to interest in nonoperative treatments for clubfoot (Ponseti casting and French Physiotherapy). Current studies show good sagittal kinematic motion after both treatments in the young child, but changes in plantar loading after these treatments have not yet been reported. Methods Pedobarograph data were collected with the Emed System on 151 clubfeet, treated with either Cast (79 feet) or physiotherapy (PT, 72 feet), at the age of 2 years. Medial and lateral differences in plantar pressures, contact area, and contact time, were assessed in the hindfoot, midfoot, and forefoot. An assessment of forefoot adductus was made, while the center of the pressure line was tracked both medially and laterally. Seventeen controls were used for comparison. Results When comparing Cast feet with PT feet, most differences in plantar pressures were found in the hindfoot and medial midfoot. Peak pressure, maximum force, and pressure time integral were all found to be decreased in the medial hindfoot after PT compared with casting. Maximum force was also less in the lateral hindfoot and peak pressure was less in the medial midfoot for the PT feet compared with the Cast feet. When compared with controls, both Cast and PT feet had increased pressure, force, contact time, contact area, and pressure time integral in the lateral midfoot, whereas the same measures were all significantly decreased in the first metatarsal region. Forefoot adductus was present in both groups compared with controls. The center of the pressure line was significantly displaced to the lateral side of the foot in both groups; however, when assessing medial displacement, only the PT feet had significantly less medial distribution compared with control feet. Conclusion Pedobarography illustrates residual pressure differences during gait in children with nonoperatively treated clubfeet. These data provide a more detailed description of dynamic foot loading and residual deformity than sagittal plane kinematics alone. Level of Evidence Therapeutic Level II

Effect of amputation level on energy expenditure during overground walking by children with an amputation.

BACKGROUND The oxygen cost of walking by adults with an amputation has been well described, but few studies have focused on this parameter in children who have had an amputation. Children with a transtibial amputation have been reported to maintain walking speed at a 15% higher oxygen cost than able-bodied children. The purpose of this study was to determine if the level of amputation in children has a differential impact on the self-selected speed of walking and the oxygen cost, and how the performance of these children compares with that of a group of able-bodied children. METHODS Seventy-three children who had had an amputation participated in this study. Oxygen consumption was measured with a Cosmed K4b2 oxygen analysis telemetry unit (Rome, Italy) as the participants walked overground for ten minutes at a self-selected speed. One minute of steady-state data were reduced, averaged, and standardized to control values. Children with a unilateral amputation were grouped according to the level of the amputation; there were twenty-nine Syme, thirteen transtibial, fourteen knee disarticulation, five transfemoral, and five hip disarticulation amputations. Seven children had had a bilateral amputation, and they were considered as a separate group. Comparisons were made among the five amputation groups and between all children who had undergone amputation and control subjects. The variables that were analyzed were resting VO(2) rate (mL/kg/min), resting heart rate (beats per minute [bpm]), walking VO(2) rate (mL/kg/min), walking VO(2) cost (mL/kg/m), walking heart rate (bpm), and self-selected walking velocity (m/min). RESULTS Unilateral transfemoral and hip disarticulation amputations resulted in significantly reduced walking speed (80% and 72% of normal, respectively) and increased VO(2) cost (151% and 161% of normal, respectively), while the heart rate was significantly increased in the hip disarticulation group (124% of normal). Compared with the controls, the children with a bilateral amputation walked significantly slower (87% of normal), with an elevated heart rate (119% of normal) but a similar energy cost. Children with a Syme amputation, transtibial amputation, or knee disarticulation walked with essentially the same speed and oxygen cost as did normal children in the same age group. CONCLUSIONS Children with an amputation through the knee or distal to the knee were able to maintain a normal walking speed without significantly increasing their energy cost. Only when the amputation is above the knee do children walk significantly slower and with an increased energy cost.

Gait analysis of children treated for moderate clubfoot with physical therapy versus the Ponseti cast technique.

Background Nonoperative methods for clubfoot treatment include the Ponseti technique and French functional method. The purpose of this study was to compare the gait of children presenting with moderate clubfeet who were treated successfully with these techniques. We hypothesized: (1) no difference in gait parameters of moderate clubfeet treated with either of these nonsurgical techniques and (2) gait parameters after treatment for less severe feet would more closely approximate normal gait. Methods Patients whose clubfeet were initially scored between 6 and <10 on the Dimeglio scale underwent gait analysis at the age of 2 years. Kinematic evaluation of the ankle was analyzed and kinematic data were classified as abnormal if more than 1 standard deviation from age-matched normal data. Spearman nonparametric correlation coefficients were used to analyze combined data of moderate to very severe clubfeet to determine any relationship between initial severity and gait outcomes. Results Gait analysis was performed on 33 patients with 40 moderate clubfeet [17 Ponseti, 23 French physical therapy (PT) feet]. Three Ponseti feet were excluded because they had undergone surgery. No statistically significant differences existed in ankle equinus, dorsiflexion, or push-off plantarflexion between the groups. Swing phase foot drop was present in 6 PT feet (26%) compared with zero Ponseti feet (P=0.026). Normal kinematic ankle motion was present more often in the Ponseti group (82%) than PT (48%) (P=0.027). Regardless of treatment, residual intoeing was seen in one-third of children with moderate clubfeet. The combined group of moderate and severe clubfeet showed no correlation between initial Dimeglio score and presence of normal ankle motion or normal gait at 2 years-of-age. Conclusions Normal ankle motion was documented more frequently in the Ponseti feet compared with the PT group. Recent implementation of early tendo-achilles release in PT feet may change these outcomes in the future. In conclusion, gait in children with moderate clubfeet is similar to those in patients with severe clubfeet, but the likelihood of surgery may be less. Level of Evidence Therapeutic level II.

Plantar pressures following anterior tibialis tendon transfers in children with clubfoot.

Background: Relapses following nonoperative treatment for clubfoot occur in 29% to 37% of feet after initial correction. One common gait abnormality is supination and inversion of the foot caused by an imbalance of the anterior tibialis tendon muscle. The purpose of this study was to determine if plantar pressures are normalized following an anterior tibialis tendon transfer (ATTT). Methods: Thirty children (37 clubfeet) who underwent an ATTT, were seen for plantar pressure testing preoperatively and postoperatively. Each foot was subdivided into 7 regions: medial/lateral hindfoot and midfoot, and the forefoot (first, second, and third to fifth metatarsal heads). Variables included: contact time as a percentage of stance time (CT%), contact area as a percentage of the total foot (CA%), peak pressure (PP), hindfoot-forefoot angle (H-F), location of initial contact, and deviation of the center-of-pressure line (COP). Paired t tests were used for group comparisons, whereas multiple comparisons were assessed with ANOVA (&agr; set to 0.05 with Bonferroni correction). Results: Significant changes were seen in preoperative to postoperative comparison. PP, CT%, and CA% had significant increases in the medial hindfoot, midfoot, and first metatarsal regions, whereas the involvement of the lateral midfoot and forefoot were reduced. Compared with controls, postoperative results following ATTT continue to show increased PP, CA%, and CT% in the lateral midfoot, increased CA% and CT% in the lateral forefoot, whereas CA% was decreased in the first metatarsal region. Compared with controls, the COP line continues to move laterally and the H-F angle continues to show forefoot adductus following ATTT. No differences were found between patients treated with an isolated ATTT and those treated with concomitant procedures. Conclusions: The changes seen in plantar pressures following ATTT would suggest that the foot is better aligned for a more even distribution of pressure throughout the foot, but is not fully normalized. Level of Evidence: Therapeutic level II.

Intensity and duration of activity bouts decreases in healthy children between 7 and 13 years of age: a new, higher resolution method to analyze StepWatch Activity Monitor data

Assessment of physical, ambulatory, activity using accelerometer-based devices has been reported in healthy individuals across a wide range of ages, as well as in multiple patient populations. Many researchers who utilize the StepWatch Activity Monitor (SAM) rely on the default settings for data collection and analysis. A comparison was made between the standard output from the SAM software, and a novel method to evaluate all walking bouts using an Intensity-Duration-Volume (I-D-V) model in healthy children aged 7-13. 105 children without impairment wore the SAM for a total of 1691 d. Statistically significant differences were seen between 7-8-9 year olds and 10-11-12 year olds using the I-D-V model that were not seen using the standard SAM software default output. The increased sensitivity of this technique could be critical for observing the effect of various interventions on patients who experience physical limitations. This new analytical model also allows researchers to monitor activity and exercise-type behavior in a way which coincides with exercise prescription by assessing intensity, duration and volume of activity bouts.

Plantar pressures after nonoperative treatment for clubfoot: Intermediate follow-up at age 5 years

Introduction: Worldwide, a nonoperative approach in the treatment of idiopathic clubfoot has been taken in an attempt to reduce the incidence of surgical outcomes. Although both the Ponseti casting (Ponseti) and the French physiotherapy (PT) methods have shown gait and pedobarograph differences at age 2 years, improved gait results have been reported by age 5 years. The purpose of this study was to assess plantar pressures in feet treated with the Ponseti versus the PT methods at this intermediate stage. Methods: Clubfoot patients treated nonoperatively (Ponseti or PT) underwent pedobarograph data collection at age 5 years. The foot was subdivided into the medial/lateral hindfoot, midfoot, and forefoot regions. Variables included Peak Pressure, Maximum Force, Contact Area%, Contact Time%, Pressure Time Integral, the hindfoot-forefoot angle, and displacement of the center of pressure (COP) line. Twenty controls were used for comparison. Results: Pedobarograph data from 164 patients (238 feet; 122 Ponseti and 116 PT) showed no significant differences between the Ponseti and the PT feet, except the PT feet had a significantly less medial movement of the COP than the Ponseti feet (P=0.0379). Compared with controls, both groups had decreased plantar pressures in the hindfoot and first metatarsal regions, whereas the midfoot and lateral forefoot experienced significant increases compared with controls. This lateralization was also reflected in the hindfoot-forefoot angle and the COP. Conclusions: Feet that remain nonoperative and avoid surgical intervention are considered a good clinical result. However, pedobarograph results indicate mild residual deformity in these feet despite clinically successful outcomes. Level of Evidence: Level II—therapeutic.

A Longitudinal Review of Gait Following Treatment for Idiopathic Clubfoot: Gait Analysis at 2 and 5 Years of Age.

Background: Initial correction following nonoperative (NonOp) treatment for idiopathic clubfoot has been reported in 95% of feet by age 2; however, by age 4, approximately one third of feet undergo surgery due to relapse. The purpose of this study was to assess the longitudinal effect of growth and surgical (Sx) intervention on gait following NonOp and Sx treatment for clubfoot. Methods: Children with idiopathic clubfoot were seen for gait analysis at 2 and 5 years of age. Kinematic data were collected at both visits, and kinetic data were collected at age 5 years. Group comparisons were made between feet treated with the Ponseti casting technique (Ponseti) and the French physical therapy method (PT) and between feet treated nonoperatively and surgically. Comparisons were made between feet treated with a limited release or tendon transfer (fair) and those treated with a full posteromedial release (poor). The &agr; was set to 0.05 for all statistical analyses. Results: Gait data from 181 children with 276 idiopathic clubfeet were collected at both age 2 and 5 years. Each foot was initially treated with either the Ponseti (n=132) or PT (n=144) method but by the 5-year visit, 30 Ponseti and 61 PT feet required surgery. Gait outcomes showed limitations primarily in the Sx clubfeet. Normal ankle motion was only present in 17% of Ponseti and 21% of PT feet by age 5 following Sx management. Sx PT feet showed persistent intoeing at age 2 and 5. Within the Sx group, feet initially treated with PT had a clinically significant reduction in ankle power compared with those treated initially by the Ponseti method. Feet treated with posteromedial releases had significantly less ankle power than those treated with limited surgery or that remained NonOp at 5 years. Conclusions: This longitudinal study shows subtle changes between 2 and 5 years, and continues to support a NonOp approach in the treatment of clubfoot. Level of Evidence: Level II—therapeutic.

The Relationship Between Gait, Gross Motor Function, and Parental Perceived Outcome in Children With Clubfeet.

Background: Assessment of children treated nonoperatively for idiopathic clubfoot, has primarily focused on the kinematic and kinetic results measured with gait analysis (GA). Excellent results in ankle motion and push-off power during gait have been reported at age 5; however, the assessment of gross motor function, has not been evaluated. The purpose of this study was to look at the relationship between gait measures, Peabody Developmental Motor Scales and parent-perception of their child’s outcome [measured with the Pediatric Outcomes Data Collection Instrument (PODCI)]. Methods: A total of 81 children with idiopathic clubfoot were seen for both GA and Peabody testing. Children who initially underwent the Ponseti technique (n=29), the French Physical Therapy method (PT) (n=23), and a group of children initially treated nonoperatively, but who required surgical intervention before GA at 5 years of age (n=29) were enrolled. Pearson’s correlation coefficient was used to establish significant relationships between gait variables, Peabody, and PODCI scores. Results: Gait data showed that the Ponseti treated feet had significantly greater ankle power than feet treated surgically (P=0.0075). The Peabody results showed that the PT feet had higher stationary (P=0.0332) and overall gross motor quotient percent (GMQ%) scores (P=0.0092) than the surgical feet. No differences were found in PODCI scores. Ankle power was weakly correlated to the GMQ% (r=0.29; P=0.0102); however, the GMQ% showed a strong correlation to the parent report of Global Functioning Scale on the PODCI (r=0.48; P=0.0005). Conclusions: Minimal gait disturbances do not interfere with function or parental assessment of abilities and satisfaction at 5-year follow-up in children with idiopathic clubfeet. Nonoperative correction of clubfeet should be the goal when possible, as the Peabody scores show better function as early as 5 years of age when surgery is not required. Level of Evidence: Level II—therapeutic.

Comparison of gait after Syme and transtibial amputation in children: factors that may play a role in function.

BACKGROUND Preservation of maximal limb length during amputation is often recommended to maximize the efficiency and symmetry of gait. The goals of this study were to determine (1) whether there are gait differences between children with a Syme (or Boyd) amputation and those with a transtibial-level amputation, and (2) whether the type of prosthetic foot affects gait and PODCI (Pediatric Outcomes Data Collection Instrument) outcomes. METHODS Sixty-four patients (age range, 4.7 to 19.2 years) with unilateral below-the-knee prosthesis use (forty-one in the Syme group and twenty-three in the transtibial group) underwent gait analysis and review of data for the involved limb. The twelve prosthetic foot types were categorized as designed for a high, medium, or low activity level (e.g., Flex foot, dynamic response foot, or SACH). Statistical analyses were conducted. RESULTS Kinematic differences of <4° in total prosthetic ankle motion and 8° in external hip rotation were seen between the Syme and transtibial groups. Ankle power was greater in the transtibial group, whereas the Syme group had greater coronal-plane hip power (p < 0.05). Prosthetic ankle motion was significantly greater in the high compared with the medium and low-performance feet. However, the PODCI happiness score was higher in patients with low compared with medium-performance feet (p < 0.05). CONCLUSIONS Small differences in prosthetic ankle motion and power were found between children with Syme and transtibial amputations. Ankle motion was greater in patients using high-performance feet (9% of the total cohort) compared with medium-performance (59%) and low-performance (31%) feet. Despite the increased ankle motion achieved with high-performance dynamic feet, this advantage was not reflected in peak power of the prosthetic ankle or the PODCI sports/physical functioning subscale. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.