The value of screening programs for pediatric foot problems—primarily flatfoot—was recently challenged in a commentary by Australian podiatrist Angela Evans, PhD, a researcher and lecturer in the Division of Health Sciences at the University of Adelaide.
This summer, in the Journal of Foot and Ankle Research, Evans examined the Australian practice of school-based screening and found it wanting from the perspective of World Health Organization (WHO) criteria. Reaction in the US has been muted because there are few such programs here, but Evans’s paper may serve as a caveat to those who want to start them—and some do.
WHO guidelines specify that screening programs for health conditions should meet several criteria: the problem should be important and clearly defined; it should be recognizable while latent or at an early symptomatic stage, and its natural history adequately understood; and treatment should modify its course.
“These criteria are not fulfilled for pediatric flatfoot,” Evans told LER.
Her paper points out that developmental (sometimes called physiologic or normal) flatfoot occurs in 45% of preschool children, but decreases to 15% in 10-year-olds as the foot develops.
“Some flat feet do remain in older children,” she said, “but unless they’re symptomatic, the need to treat is unclear.”
So why screen? Some argue that pediatric flatfoot shouldn’t necessarily be the focus.
“We need more screening, not less, because there are huge numbers of children in the US with foot malalignments that are not identified until they are well into adulthood, when they have significant problems,” said Russell Volpe, DPM, professor of orthopedics and pediatrics at the New York College of Podiatric Medicine in New York City.
Volpe includes femoral or tibial torsion, equinus, and genu varum among problems that could be identified or prevented through screening.
For Ron Raducanu, DPM, who practices in Philadelphia and serves as president of the American College of Foot and Ankle Pediatrics (ACFAP), the argument against screening doesn’t take a long enough time frame into consideration.
“They’re not following these children into adulthood, so they don’t know if the kids experience pain as they get older,” Raducanu said. “Is there malalignment of the joints? Does it resolve? Are there very flat feet, or in-toeing, or hip problems? If screening can prevent even one percent of them from having issues down the road, then we are doing our jobs.”
Louis DeCaro, DPM, who practices in Amherst, MA, and is vice president of the ACFAP, plans to roll out a school screening program to help identify at-risk foot types in the near future, beginning with an assessment of the methodology in his local district.
“I agree with Dr. Evans that the way foot screenings have been done is a waste of time,” DeCaro said. “Basically, they’re checking for flat-footedness, which has flaws related to subjectivity and doesn’t consider the natural maturity of the foot. When we go into the schools, I propose putting every child into one of six categories, taking a brief social and family history, and assessing other symptoms such as coordination, fatigue, and endurance.”
DeCaro’s goal is to train school nurses to assess children’s foot types according to his system, then sort the data and refer to the appropriate specialists.
The problem with such an approach, according to Edwin Harris, DPM, is that there may be so many potential issues associated with each category that school nurses could end up classifying nearly every foot as pathological. Harris, an associate professor of orthopedics and rehabilitation at Loyola University Medical Center in Maywood, IL, saw a similar phenomenon when he was involved in school screening for scoliosis 20 years ago.
“It led to the term ‘schooliosis,’ because orthopedists were dealing with this huge incidence of false positive screening results,” he said. “If you’re going to use the kind of classification DeCaro proposes, you have to have some feet that are considered normal, and the number of classifications cannot lead to a high incidence of false positives. The instrument must be validated to ensure that it accurately identifies cases with a high risk of future pathology. Also, it must be possible to train school nurses to use the instrument as accurately as a podiatrist, with a low rate of false positives.”
Cary Groner is a freelance writer in the San Francisco Bay Area.
Sources:
Evans AM. Screening of foot problems in children: is this practice justifiable? J Foot Ankle Res 2012; 5(1):18.
An Austrian study exploring the role of genu valgum and flatfoot in obese and normal weight children found obesity was associated with higher peak plantar pressures, but lower maximum force while walking, when forces were normalized to body weight.
The findings suggest compensation may occur in gait and that dynamic measures may be more clinically important than static views.
Lead author Robert Bernecker, MS, and his team at the University Clinic for Physical Medicine & Rehabilitation in Salzburg, Austria, analyzed 34 children, 13 of whom were obese (mean body mass index of 31.2) and had genu valgum and/or flatfoot. Using a force platform system, the researchers assessed contact area, maximum force, and peak pressure during 10-second single-leg stands and during gait; they also assessed contact time during gait.
For the static condition, obesity was associated with significantly greater contact area. During gait, obesity was associated with significantly higher peak pressures and greater contact time for all areas of the foot except the toes, but lower normalized maximum force in the hind foot and the big toe. The findings were presented in August at the Expert Scientific Meeting, held in Aalborg, Denmark.
The lower normalized dynamic forces in the heavier children may indicate some type of compensatory gait adaptation. However, a slower gait in the obese children than in the normal-weight children may also have contributed to the findings, Bernecker said.
Bernecker believes a future study comparing a different static measure to traditional dynamic assessment is needed to elucidate his preliminary conclusions.
“The maximum peak force, not normalized, is a more widely used parameter in scientific literature, and this parameter was significantly higher in our findings compared with those found in the extensive research by Dowling and Mickle,” he said. “It would be interesting to find out about their maximum forces normalized to body weight.”
Sarah Shultz, PhD, ATC, a lecturer in exercise and sport science at Massey University in Wellington, New Zealand, and lead researcher of orthopedic complications of childhood obesity, highlighted the Austrian findings of increased contact area during standing and increased plantar pressures during gait in the obese children.
“What is remarkable is that the obese children are displaying larger contact area during static standing [which is often seen as a mechanism for maintaining balance] and still showing greater peak pressures during walking,” she said.
Shultz’s concern is that surface areas of children’s bones do not grow proportionately to their weight.
“Bones and joints that are absorbing the impact of these forces are not any larger than those in a child who does not carry extra mass,” she said.
Injuries that may occur as a result of increased force when obese children compensate or modify their gait include stress fractures and plantar fasciitis, Shultz said.
“There are also possible implications farther up the lower extremity kinetic chain, which is already evident in the obese children in the Bernecker study who display genu valgum,” she said.
The genu valgum, in fact, may be a more critical risk factor for future pathology than flatfoot, Bernecker said.
“Orthopedically, the first concern is the valgus misalignment, not the foot,” Bernecker stressed.
He anticipates future studies that identify the age of obesity onset might better indicate the point at which it leads to genu valgum.
“Moreover, it would be a great idea to compare obese children with different characteristics concerning genu valgum and flatfoot,” he added.
Michele M. Zembo, MD, MBA, assistant dean for clinical education at Tulane University School of Medicine in New Orleans, has treated many overweight children in more than 25 years of practicing pediatric orthopedic surgery.
Dynamic studies, including gait analysis, are an essential component of evidence-based clinical decisions that also depend on experience and observation, Zembo said, but there is also a role for static measures.
“The majority of foot problems in obese children that families worry are deformities are actually caused by poor-fitting shoes,” she said. “In such cases, a static footprint placed on the upturned shoe sole is essential for explaining what is happening to the child’s foot inside that shoe every day.”
Christina Hall Nettles is a freelance writer based in Monroeville, AL.
Sources:
Bernecker R, Weghuber D, Landauer F, et al. Does genu valgum and/or flatfoot play a role in dynamic plantar pressures and static footprints in obese and non obese children? Presented at the 13th Expert Scientific Meeting, Aalborg, Denmark, August 2012.
Dowling AM, Steele JR, Baur LA. What are the effects of obesity in children on plantar pressure distributions? Int J Obes Relat Metab Disord 2004; 28(11):1514-1519.
Mickle KJ, Steele JR, Munro BJ. Does excess mass affect plantar pressure in young children? Int J Pediatr Obes 2006;1(3):183-188.
Research has recently begun to clarify footwear’s effects on gait and functional performance in children, but the broader implications of the findings remain a matter of debate.
At the 2012 International Foot & Ankle Biomechanics (i-FAB) Congress in Sydney, Australia, researchers from the University of Sydney presented a poster delineating the difference between children’s performance barefoot and in athletic shoes. The researchers had nine boys and 10 girls (mean age, 10 years) perform four activities barefoot, then in athletic shoes, in a randomized order. The activities were a single-leg balance test (eyes open, then closed); a standing long jump; and a timed running agility test in which the subjects ran 10 m four times (they picked up an object at the end of one 10-m leg, carried it on the next leg, dropped it, and picked up another to carry—hence the “agility” aspect of the test).
The researchers reported that shoes did not alter single-leg balance whether subjects’ eyes were open or shut, nor did they have any significant effect on running agility. Shoes did, however, improve standing long jump performance; the authors speculated that this may have been due to a perception of better protection, improved friction between the outsole and the carpeted surface, better transfer of force from the calves, or some combination of these.
Lead author Caleb Wegener, an Australian podiatrist and PhD candidate at the university, told LER that additional data, unavailable at the time of the conference, showed that shoes negatively affected standing jump height—an effect possibly caused by the shoes’ weight.
An earlier review by Wegener and his colleagues found that about 75% of pediatric gait variables differed between walking barefoot and wearing shoes. Shod children walked faster, taking longer steps with greater ankle and knee motion and increased tibialis anterior activity; on the other hand, shoes reduced foot motion and increased the support phase of gait. During running, shoes had three primary effects: a reduction in swing-phase leg speed, shock attenuation, and encouragement of a rearfoot strike pattern.
Other studies have reported similar results. For example, a 2009 paper by Lythgo et al in Gait & Posture reported that children’s gait speed, step length, stride length, support base, and step and stride time all increased with athletic footwear, whereas foot angle and cadence decreased. Another of Wegener’s studies found that children’s school shoes increased sagittal ankle motion during loading and propulsion, but decreased frontal plane motion during midstance and propulsion.
The practical implications of such research remain to be determined, Wegener acknowledged.
“Shoes reduce motion, which could reduce the stimulus to the muscles, which could impede muscular development,” Wegener said. “But we need to confirm that hypothesis.”
In fact, when younger, Wegener often competed in track and field events barefoot, on a grass track. He acknowledges that barefoot athletic competition has its limits, however.
“I’d never play soccer or basketball barefoot,” Wegener said. “Shoes do change the way the foot functions—but they also provide protection.”
Russell Volpe, DPM, professor of orthopedics and pediatrics at the New York College of Podiatric Medicine in New York City who has written about athletic footwear for children, examined the studies by Wegener and others and concluded that the reported gait and performance changes are probably neutral to positive.
“These are fairly minute gait changes,” he said. “Some are biomechanically logical changes in sagittal plane ankle motion, and there are other principles of the effect of shoes on gait that can be extrapolated to how they’ll affect children.”
Volpe does think that, where children are concerned, minimal is better.
“I generally like a lighter-weight shoe with soles that aren’t too thick,” he said. “It should have a firm counter to prevent excessive rearfoot motion, and it should bend easily in the ball.”
Volpe rejects the idea suggested by some that wearing shoes weakens the feet, however.
“There’s no evidence that the development of the muscles of the longitudinal arch is hampered by shoes,” he said. “But in a child, you don’t want anything so heavy or bulky that it’s going to cause bigger alterations in gait.”
Cary Groner is a freelance writer in the San Francisco Bay Area.
Sources:
1. Wegener C, Greene A, Millar R, et al. Children’s functional performance barefoot and in sports shoes. J Foot Ankle Res 2012;5(Supp1):31.
2. Wegener C, Hunt AE, Vanwanseele B, et al. Effect of children’s shoes on gait: a systematic review and meta-analysis. J Foot Ankle Res 2011;4:3.
3. Lythgo N, Wilson C, Galea M. Basic gait and symmetry measures for primary school-aged children and young adults whilst walking barefoot and with shoes. Gait Posture 2009;30(4):502-506.
4. Wegener C, O’Meara D, Hunt AE, et al. Three-dimensional ankle kinematics in children’s school shoes during running. J Foot Ankle Res 2012; 5(Supp1):20.
Timing of reconstruction surgery after pediatric anterior cruciate ligament (ACL) injuries seems to be related to the prevalence of meniscal and chondral injuries discovered during those surgeries, according to new research published in the September issue of The American Journal of Sports Medicine.
Researchers from the University of Texas Southwestern Medical Center in Dallas retrospectively reviewed the records of 241 pediatric patients who had undergone primary ACL reconstruction 150 days from injury or sooner and 129 patients treated more than 150 days out. In the early group, 37.8% had medial meniscal tears (MMTs) versus 53.5% in the delayed group; rates of lateral meniscal tears (LMTs) were similar (about 57%) in both groups. Patients with meniscal tears, moreover, were more likely to have a chondral injury in that compartment.
“The historical treatment algorithms, in terms of leaving these injuries alone, have been based on the hope that the children would heal. But the meniscus is not a highly vascular structure, especially as you move toward the inside, so our hopes of it healing itself may be unfounded,” said Guillaume Dumont, MD, chief resident in orthopedic surgery at the University of Texas Southwestern Medical Center in Dallas, and the paper’s lead author. “Children are more active than the rest of the population, so we may see a higher prevalence of injury down the line in younger kids with ACL-deficient knees, just because they’re the ones who are participating in sports every day and running around the schoolyard.”
That activity level may contribute to the increased prevalence of meniscal injuries associated with delayed surgery in the study, said Darin Padua, PhD, ATC, a professor in the Department of Exercise and Sports Science and director of the Sports Medicine Research Laboratory at the University of North Carolina at Chapel Hill.
“The ACL plays an important role in stabilizing the motion of the tibia on the femur,” Padua said. “In those 150 days of moving around, the patient may induce a meniscal or cartilage injury that wasn’t there initially.”
Such collateral damage increases the risk of subsequent osteoarthritis (OA), a particularly troublesome prospect in young patients, Padua noted.
“If a kid with a torn ACL decides to delay surgery, then goes on to damage their meniscus, they are at high risk for getting OA in their twenties or thirties,” he said.
Although the study suggested that delayed surgery may lead to higher rates of meniscal injury, other experts have urged caution in interpreting those results.
“The study documents the status of the meniscus at the time of surgery, but not at the time of injury,” noted Cynthia LaBella, MD, associate professor of pediatrics at Northwestern University’s Feinberg School of Medicine, and medical director for the Institute for Sports Medicine at the Ann & Robert H. Lurie Children’s Hospital of Chicago. “As a result, we don’t know whether those meniscal tears were a result of the initial trauma or accumulated during the interval between it and surgery.”
It’s an important distinction, LaBella said, because if the meniscal damage occurred concurrent to the ACL injury, elapsed time to surgery isn’t as crucial as it would be if the meniscal damage resulted later due to unstable, ACL-deficient knees.
“I don’t think you can conclude that delay led to meniscal injuries,” she said. “You can say there’s an association, but we have no way of knowing whether the patients started out with those meniscal injuries at the time of trauma.”
“It would be great to see what the rate of meniscal injury was one day after the ACL tear, then compare it as time went on,” agreed Dumont. “This was an observational study done at the time of surgery, but I think it makes sense that if you have an unstable knee, and there are structures inside it that are undergoing abnormal stresses, it’s more likely to sustain meniscal injury.”
Regarding the findings that patients had more lateral than medial meniscal tears—but that the lateral tear rate wasn’t affected by the time lag between injury and surgery—Dumont noted that this is also seen in adult populations.
“Adults with an acute ACL tear are more likely to have a lateral meniscus tear associated with it, and as time goes on the rate of medial meniscal tears increases. It’s difficult to say exactly what motion in the knee is causing that, but it indicates to me that there are abnormal stresses in the medial compartment of the ACL-deficient knee,” Dumont said.
Cary Groner is a freelance writer in the San Francisco Bay Area.
Source:
Dumont GD, Hogue GD, Padalecki JR, et al. Meniscal and chondral injuries associated with pediatric anterior cruciate ligament tears: relationship of treatment time and patient-specific factors. Am J Sports Med 2012;40(9):2128-2133.
Photo by Vincent Giordano/Trinacria Photography (www.trinacriaphotography.com), courtesy of Clinical Prosthetics & Orthotics.
Issues involve custom foot orthoses
By Larry Hand
A Scottish study suggests foot care in children with juvenile idiopathic arthritis (JIA) falls short because of poor access to care and negative perceptions about custom foot orthoses. Experts say those issues may be less prevalent in the US but emphasize the need to educate patients, parents, and referring clinicians about the benefits of lower extremity care.
The study, published online in July in the Archives of Physical Medicine and Rehabilitation, identified six key themes that emerged from conversations with four teenaged patients, two parents, three pediatric rheumatologists, and six other healthcare professionals. The participants were from two National Health Service rheumatology centers in Glasgow, UK.
Patients identified pain as the main impact of the disease, and cited physical activity and footwear problems as causes of pain. However, patients said they were “prepared to endure high levels of pain and stiffness” if they could maintain mobility, which was the main impact of disease cited by healthcare professionals and parents. Patients also perceived that pain and mobility impairment interfered with their abilities to perform everyday tasks or participate in sports, which also resulted in feelings of distress, depression, and isolation.
Patients and parents all reported problems finding appropriate and comfortable shoes. All participants complained about lack of access to lower extremity specialists. The healthcare professionals expressed reluctance to refer because they perceived a lack of evidence supporting the effectiveness and cost efficiency of foot orthoses for JIA patients. While some considered the devices beneficial for easing pain, others considered foot orthoses “as a waste of time and money due to noncompliance.”
“Finding solutions for footwear difficulties experienced in this patient group is challenging,” said lead author Gordon J. Hendry, PhD, formerly of Glasgow Caledonian University and now a lecturer in podiatric medicine at the University of Western Sydney in Australia. “Further research is required to determine what aspects of footwear are important to parents, as well as young and adolescent boys and girls.”
Further research is needed on how, specifically, foot orthoses affect foot mechanics and inflamed joints and soft tis- sues, and if the benefits of custom foot orthoses justify the costs, Hendry said.
“The current evidence suggests that customized foot orthoses are reasonably effective in reducing foot pain in inflammatory arthritis conditions,” he said. “There is as yet no significant evidence that foot orthoses halt the destructive inflammatory processes associated with conditions such as rheumatoid arthritis and JIA. This question needs to be addressed through clinical trials using sensitive imaging techniques.”
The study’s findings related to access to care likely are not what one would find in the US, said Russell Volpe, DPM, professor of orthopedics and pediatrics at the New York College of Podiatric Medicine in New York City.
Noting that the effectiveness of foot orthoses for pain reduction in juvenile arthritis was documented in a 2005 randomized study by Powell et al published in the Journal of Rheumatology, Volpe suggested that the effects on pain alone should be enough to justify the use of foot orthoses.
“The already documented ability of FOs to reduce pain in juvenile arthritis patients should be enough to see that these children get into appropriate FOs,” Volpe said.
The 2005 study found that 15 children with JIA wearing custom semirigid foot orthoses with shock-absorbing posts experienced significantly greater improvement in pain and function at three months than children who only used supportive athletic shoes or off-the-shelf shoe inserts. The authors argued that the cost of the custom orthoses ($250—$350 per pair) over time would be less than other medical interventions.
However, the study authors also wrote that, because materials and methods used in fabricating custom orthotics vary, “the needs of the patient, whether accommodative, biomechanical, or functional, influence the choice of orthotic.”
If the patients in this recent study had better access to lower extremity care, Volpe said, many more of them would have been able to benefit from the pain-reducing effects of foot orthoses.
“In the face of the Powell study, that some of the clinicians thought FOs were a ‘waste of time’ betrays a sad ignorance on their part,” he said.
Larry Hand is a writer based in Massachusetts.
Sources:
Hendry GJ, Turner DE, Lorgelly PK, Woodburn J. Room for improvement: patient, parent, and practitioners’ perceptions of foot problems and foot care in juvenile idiopathic arthritis. Arch Phys Med Rehabil 2012 Jul 25 [Epub ahead of print]
Powell M, Seid M, IS. Efficacy of custom foot orthotics in improving pain and functional status in children with juvenile idiopathic arthritis: a randomized trial. J Rheumatol 2005;32(5):943-950.
The surrogate biomodel undergoes testing in Andrew DiMeo’s lab. Photo courtesy of Andrew DiMeo, PhD.
Method includes complex rotations
By Emily Delzell
A surrogate biomodel of a child’s lower extremities, in particular the ability to model movement along multiple axes of rotation, could help improve researchers’ biomechanical understanding of bracing for clubfoot.
The multicenter team of investigators who developed the biomodel reported on their testing of the complex surrogate in September in the Journal of Pediatric Orthopaedics (JPO).
Clinicians now achieve high rates of clubfoot deformity correction using the Ponseti method (See, “Clubfoot conversion: Nearly all surgeons adopt Ponseti method”); once corrected, however, children’s feet retain a stubborn tendency to relapse. Children who stop postcorrection brace use at 2 years have relapse rates of up to 56%; among children who wear braces until they are aged at least 4 years, the relapse rate is 11%, study authors reported.
“Dr. [Ignacio] Ponseti revolutionized treatment of children with clubfoot by turning a debilitating surgery into a gentle manipulation. His method, however, relies heavily on patient compliance to wear a brace for up to five years after correction,” said study lead author Andrew DiMeo Sr, PhD, director of industrial relations and assistant professor of the practice in the University Joint Department of Biomedical Engineering at North Carolina State University and the University of North Carolina at Chapel Hill.
In an attempt to improve both the bracing itself as well as patient compliance, DiMeo and colleagues designed a surrogate biomodel with the biomechanics of a 5-year-old child, featuring complete lower extremity anatomy with joint articulation and kinematic capabilities.
Investigators based the model on anthropometric data detailed in a reference text of normal human measurements.
“We then used the Ponseti Training Model as starting point, converting the physical model into image data using x-ray computed tomography, converting that image data into solid models, scaling the solid models to match that of an average 5-year-old, then using rapid prototyping to convert the scaled solid model back into a physical form,” DiMeo explained.
The biomodel’s components include skeletal structure constructed from acrylonitrile butadiene styrene (ABS) resin and muscle-tendon systems and ligaments made from springs, cables, and elastic cord. The JPO paper validated the biomodel’s reliability and repeatability for measuring forces applied by different braces, demonstrating an error rate between 1% and 6%.
Co-investigator Jose Morcuende, MD, PhD, associate professor of orthopedic surgery at the University of Iowa in Iowa City, told LER that problems of compliance with clubfoot bracing, which are largely dictated by patient comfort, are compounded by a lack of evidence and consensus regarding optimal brace para- meters, including spring lengths and loads applied to muscle-tendon systems. The biomodel, DiMeo said, can characterize and a compare a number of brace parameters, including bar width, external rotation, and dorsiflexion angle.
“We have clinical experience showing us what works and what doesn’t, but we’ve not had a good way of testing the best position to produce an optimal stretch without having difficulties with the knees and the hips,” he said. “Dr. DiMeo was able to demonstrate, for example, that a too-wide bar results in a knock-kneed effect. This is something we’re pretty well aware of clinically but haven’t been able to test in the lab until now.”
DiMeo, he noted, is preparing a second paper that details the use of the biomodel to compare an ankle foot orthosis and a flexible bar brace as well as different bracing parameters.
“The surrogate model allows unbiased comparisons between braces and brace parameters. For example, the standard of care suggests a brace be worn with the bar length set to shoulder width,” DiMeo said. “What happens if the width is set slightly wider or narrower? These subtle brace adjustments can have an impact on how well correction is maintained.”
Morcuende noted lessons gleaned from the biomodel will help clinicians determine which brace types best prevent children from experiencing relapse and further treatment.
“This is the first biomechanical model to test the different bracing parameters for clubfoot and is a unique, complex model that I think will be very helpful to test the available braces and to narrow down which ones are working and which ones are not,” he said.
Sources:
DiMeo AJ, Lalush DS, Grabt E, Morcuende JA. Development of a surrogate biomodel for the investigation of clubfoot bracing. J Pediatr Orthop 2012;32(7): e47-e52.
Ankle foot orthoses (AFOs) are regularly prescribed to children with walking disabilities resulting from cerebral palsy, yet the effects of AFOs on energy recovery and work during gait are still unclear.
In a study published in the March 2012 issue of Clinical Biomechanics, researchers from the University of Virginia in Charlottesville found that although AFOs can reduce the work needed to walk for some children with cerebral palsy, they do not do so for others.
Most children had an increase in stride length, gait speed, and energy recovery, but the increase in energy recovery did not decrease the external work. Additionally, there was a great variability in the measures related to work—while use of the AFO reduced work for some children, others experienced no change or a negative effect.
“The main culprit is that longer steps result in greater energy excursions, which the improved gait mechanics could not overcome,” said Bradford Bennett, PhD, research director of the Motion Analysis and Motor Performance Laboratory and assistant professor of research in the Department of Orthopaedic Surgery at the University of Virginia School of Medicine in Charlottesville.
To examine the effects, researchers observed 21 children with spastic diplegic cerebral palsy who wore AFOs. A full body marker set of 38 markers was attached to each patient, who then walked with and without their prescribed AFOs at a self-selected speed while three-dimensional data were collected.
Devices worn by the study participants included solid AFOs and hinged AFOs with a plantar flexion stop. The results for the two groups were combined, as there was no statistically significant difference between them, Bennett said.
AFO use was associated with significant increases in stride length and gait speed, but the effect on work varied within the group. Eight of the 21 patients experienced a decrease in work of more than 10%, with an average reduction of 31%. But six patients experienced an increase in work of more than 10%; their average increase was 24%.
Overall, although AFO-assisted gait was found to be more pendular with an improved recovery factor, the external work on the user’s center of mass was not reduced as the improved mechanics were offset by increased variations of the potential and kinetic energies.
Maximum values for potential and kinetic energies were higher and minimum values were lower throughout the gait cycle for the AFO condition than the barefoot condition. This was not surprising, Bennett said, as increased stride length is known to increase energy variation. The large variations in the measured energies were offset by improved energy recovery, yet the improvements were not enough to decrease the net work.
Although these findings are not necessarily new, such research may help physicians in prescribing AFOs in the future.
“It’s worthwhile to do work like this because the more we understand how braces work, the better we are at prescribing patient by patient,” said Jon Davids, MD, assistant chief of orthopedic surgery at Shriners Hospitals for Children—Northern California in Sacramento. “Even though they’ve been used for many years, there are still many things we don’t understand about what they do and don’t do. This kind of research helps us understand these things better.”
Energy efficiency should be considered in the context of a patient’s gait mechanics, Davids said.
“It’s hard to always say which quality is the clinical priority,” he said. “If an AFO is extremely energy efficient, that would be the deciding factor. However, if there is only a subtle difference in energy expenditure but it improves stability or other aspects of gait, gait mechanics would be the deciding factor.”
According to Bennett, energy expenditure is still important even if gait mechanics are improving.
“For most of these children, and as they get older, it is the high cost of walking that is the limiting factor,” he said. “Doubling or tripling the cost of locomotion is similar to the cost if one ran very hard from place to place.”
In the end, however, it’s up to the patient.
“A brace must provide a functional benefit for children to embrace it and wear it,” Davids said. “If it doesn’t improve whatever their clinical problem is but maybe is energy efficient, it will be rejected. Comfort and function are what determine a successful outcome.”
Samantha Rosenblum is a journalism student at Northwestern University in Evanston, IL.
Source:
Bennett BC, Russell SD, Abel MF. The effects of ankle foot orthoses on energy recovery and work during gait in children with cerebral palsy. Clin Biomech 2012;27(3):287-291.
Tibialis anterior tendon transfer (TATT) is known to be associated with limited ankle dorsiflexion, but practitioners should be aware that plantar flexion also can be negatively affected, according to research presented in October at the International Clubfoot Symposium.
TATT has been shown to improve a number of ankle kinematic variables in relapsed clubfoot patients with overactive tibialis anterior muscles, but weakening of the ankle dorsiflexors can decrease dorsiflexion range of motion. For this reason, surgeons often perform TATT with the foot in a maximally dorsiflexed position, according to John Herzenberg, MD, director of pediatric orthopedics at Sinai Hospital in Baltimore. But Herzenberg and colleagues found that this technique, in some patients, appears to have an effect on passive plantar flexion.
The Baltimore researchers analyzed 17 clubfeet in 12 patients treated with TATT at a mean age of 5 years. Overall, ankle plantar flexion at follow up (at least nine months after surgery) did differ significantly from preoperative levels. But while plantar flexion was the same or better in eight feet, nine feet demonstrated reduced plantar flexion.
“While achieving dorsiflexion is emphasized as an important goal, it is equally important to maintain plantar flexion,” Herzenberg said.
In a separate symposium presentation, researchers from the UK reported findings that suggest patients are less likely to need a TATT procedure if their clubfoot management has been centralized at a single institution than if they have been shuttled between locations.
In 156 children (271 clubfeet) treated at a single center and 116 children (201 clubfeet) treated at multiple centers, investigators from Chelsea and Westminster Hospital in London found that the percentages of feet and patients undergoing TATT were significantly higher for those treated at multiple centers.
“A higher proportion of poor responders were referred to us by other centers,” said Alison Hulme, MBBS, a consultant pediatric orthopedic surgeon at Chelsea and Westminster Hospital.
Demographics in both groups were similar, including Pirani scores, Hulme said. But multicenter cases were more likely to be associated with prolonged casting, poorer compliance, and a later age at both presentation and correction.
Clubfoot correction ideally should be performed during infancy, before children learn to walk, but experts agree that the Ponseti treatment method can also be effective in older children. Speakers at the International Clubfoot Symposium in October presented successful outcomes for Ponseti treatment of neglected clubfoot in patients aged up to 21 years.
Cases of neglected clubfoot are most prevalent in underserved areas where ambulation is essential for survival, which means not only do children learn to walk on malaligned feet but also that time spent in a cast can be more than just an inconvenience. As a result, practitioners treating older children make an extra effort to keep casting to a minimum.
“Fewer casts mean less weakness. The children are better able to get their strength back,” said Julyn A. Aguilar, MD, MHA, head of the Section of Pediatric Orthopedics at St. Luke’s Medical Center in Quezon City, Philippines, who reported a 100% plantigrade correction rate in 57 feet with severe or very severe clubfoot in 37 children with a mean age of 8 years. “I also ask these kids to undergo physical therapy so they can have a normal gait as quickly as possible.”
Anna Ey Batlle, MD, a pediatric orthopedic surgeon at Sant Joan de Déu in Barcelona, Spain, who also treats patients in India, reported using a mean of just 2.2 casts per patient in 32 patients (46 clubfeet) whose ages ranged from 3 years to 21 years. Batlle, who prefers to change casts every four to five days rather than every week, achieved a mean final Pirani score of 1.1 with no relapses in her neglected clubfoot population.
Jennifer McCahill, BScPT, MPhysio, MCSP, a physiotherapist at Nuffield Orthopaedic Centre in the UK, described her group’s successful use of the Ponseti method in 15 patients (19 clubfeet) aged between 2 and 15 years who had previously undergone strapping as a primary clubfoot treatment but had relapsed to the point where they were walking on the lateral edge of the foot with no apparent heel strike.
After Ponseti casting for a mean of 7.4 weeks and, in most cases, tenotomy, lengthening, or tibialis anterior tendon transfer, all patients were heel striking and mediolaterally balanced during gait. Heel varus was corrected in 13 of 16 feet and internal foot progression was corrected in 14 of 17 feet.
Treatment of children with clubfoot has evolved considerably in the five years that have elapsed since the inaugural International Clubfoot Symposium, and the benefits of this evolution are particularly evident in resource-poor nations—home to about 80% of the 200,000 children born each year with clubfoot. But practitioners who treat patients in these areas still face financial, cultural, and logistical challenges.
The specific challenges vary by locale, but the potential consequences are the same in any language: If left untreated, all children born with the deformity suffer physical complications that compound problems with employment and full participation in their communities, said Frederick Dietz, MD, a pediatric orthopedic surgeon who has traveled the globe teaching the Ponseti method and has worked long-term to help establish national clubfoot care programs in Laos and Bangladesh.
“Clubfoot is an unusual disorder in the sense that the very best treatment—the Ponseti method—is also the cheapest and most compatible with low–resource countries. The caveat is that neglected clubfeet are difficult and expensive to treat, so the key is to turn off that tap so that all newborns are treated and can live productive lives in their society,” he said.
Dietz, a professor of orthopedic surgery at the University of Iowa in Iowa City, was a lead faculty member for the 2012 symposium, which was held October 3 to 5 at his home institution and hosted about 200 clubfoot practitioners.
This child was treated with the Ponseti method in one of Walk for Life Bangladesh’s 35 clinics, which are located so that no patient need travel more than 37 miles (60 km) from home. (Photos courtesy of Walk for Life Bangladesh.)
Nariman Abol Oyoun, MD, a clinical lecturer in orthopedic surgery at Assiut University Hospital in Assiut, Egypt, came to report on the evolution of clubfoot care in her hospital from 2006, when she was basically alone in her use of the Ponseti method, to the present, when the technique is the current standard of care.
“The results of the Ponseti method speak for themselves; it took me less than a year, and perhaps three or four presentations showing results of actual clubfeet I had treated for people to change their minds and try to learn the method,” she said.
At the symposium, Oyoun reported on Assiut’s experience with 219 patients and 336 feet. At the final postcorrection follow-up visit 89.3% feet were rated satisfactory, defined as plantigrade, flexible, and with valgus heel and little or no dynamic forefoot adduction.
Adherence to postcorrection protocols, however, is a significant problem in Assiut, she said.
“Adequate braces are hard to come by in this area and the cost of replacing braces as babies grow is out of the economic reach of many families,” she said.
Oyoun also noted issues of clinic access at her hospital, which is about 230 miles south of Cairo.
“Parents travel long distances to come to Assiut,” she said. “I try my best to give patients living far away longer intervals just to keep them linked to me in a way that wouldn’t put much stress on their lives. Some do comply, but some look for a local physician after feet are corrected. As a result, there is a percentage lost to follow up, but there is also a good percentage of relapses, patients who disappeared for a year or more and reappeared when the foot was ‘formally and officially beyond any doubt’ deformed.”
The problem of transport to clinics for the follow-up care needed to prevent relapse is common among practitioners working with global outreach programs.
An infant in the Assiut clinic wears a brace donated from Walk For Life Bangladesh. Bangladeshi cobblers manufactured the bar with an optimal bend. (Photo courtesy of Nariman Abol Oyoun, MD.)
In Bangladesh, Dietz noted, this problem was addressed at the outset of the program, which was established in 2009 by Walk For Life (WFL) with support from the Australian Glencoe Foundation, and had the specific aim of providing Ponseti treatment to all children younger than 4 years within 60 km of their homes.
The 35 WFL clinics, which have now treated 9000 feet, also benefit from a trained pool of practitioners who are evaluated and promoted based on their proficiency with the Ponseti method, Dietz said.
“Ponseti care is the sole focus of these individuals, who are physical therapists,” he said. “This is almost unique in my experience—in other places we might train nurses, orthotists, prosthetists, and other practitioners, but it’s never their primary job.”
The Bangladesh program also benefits from a robust local brace-making enterprise.
“Walk for Life arranged supplies and hired cobblers who now turn out brilliant Steenbeck braces at a cost of about four dollars,” Dietz said. “They are taking their teams abroad to teach others. It can be done anywhere with a supply of leather, metal bars, and cobblers, and it can be done cheaply. But that is a problem for most new programs—to have a range of braces on the shelf so that when feet are corrected children go directly into the boots and bars.”
Oyoun noted that while her patients greatly benefited from a donation of 117 Bangladeshi braces, much-needed local manufacture is still absent.
In Brazil, Monica Paschoal Nogueira, MD, PhD, an orthopedic surgeon at the Hospital do Servidor Público Estadual in São Paulo, and coordinator of the Brazilian Ponseti Clubfoot Project, also faces problems of brace acquisition, which can take anywhere from a week to six months and averages 30 days. Families dependent on social services wait even longer, she said.
Another infant wears what Oyoun said is the “best locally made brace available” in the Assiut region in southern Egypt. She bent the bar manually when she fitted the baby with the brace. (Photo courtesy of Nariman Abol Oyoun, MD.)
She also pointed out issues surrounding physician education in the duration of brace use.
“Inadequate duration of the postcorrection abduction brace is the primary factor associated with relapse, and insufficient prescription of the brace by physicians is a major barrier to compliance in southeastern Brazil,” she said.
At the symposium Nogueira presented results of a survey of 45 Brazilian orthopedic surgeons regarding brace use; 16 residents and 29 surgeons who had completed residency training responded. All had received formal training in the Ponseti method.
Only 25% of the residents prescribed the brace appropriately according to the Ponseti protocol, which calls for 23 hours of daily wear for three months followed by 12 to 14 hours of wear for two to four years. Appropriate brace use jumped to 65% among surgeons who had completed residencies; among these, 74% who attended postresidency Ponseti training correctly prescribed the brace, compared with 40% of surgeons without postresidency education.
Parent education regarding the importance of adhering to brace use is another problem encountered by Nogueira and her colleagues. In the Brazilian program, physicians are often the only healthcare practitioners to educate parents on proper brace use and its importance. Her study showed that physicians spent an average of only 17 minutes explaining these issues, and that only 34% of clinics in the program had any printed materials for parent education.
“Education in terms of the correct [Ponseti] protocol is key. If physicians are in doubt of the importance of the brace—that it is crucial to maintain correction—it is impossible to pass on instructions to parents in the correct way,” she said.
In Egypt, Oyoun, who lacks clinic assistants, worries that that her own efforts in that regard may be insufficient, though she says she “explains in every session the natural history, the treatment difficulties, and the false beliefs that can lead to recurrence of the deformity.” To help compensate for a lack of staff, she gives every parent her cell number for 24/7 access.
Both she and Dietz noted that a robust program, in which parents can talk to their peers at different stages of treatment and see both the successes and the consequences of not using the brace, can encourage compliance and help reduce relapses.
Pediatric orthopedic surgeon Anna Ey Batlle, MD, who presented experiences with 400 consecutive patients (1997-2009) she treated at her hospital, Sant Joan de Déu in Barcelona, Spain, noted the relapse rate in her first 100 patients was five times higher than in the last 100 babies she treated (20 vs 4, respectively).
“In the first years of the program I maintained the brace for two and a half to three years; now I maintain it for four to five years,” she said.
Her Achilles tenotomy rate has also changed dramatically, rising from 77% in the first 100 patients treated to 96% in the last 100. Her objectives with increased tenotomy were to avoid talus flattening and equinus relapse.
“The key point for a successful clubfoot program is to be absolutely strict in the Ponseti technique in every one of the steps, including manipulation, cast, braces and treatment of relapses,” Ey Batlle said.
The Ponseti method of clubfoot management has achieved worldwide acceptance, but practitioners and researchers are still working to identify the best ways to optimize clinical outcomes while remaining sensitive to issues of cost effectiveness and cultural differences. Clinicians from around … Continue reading →
Use of an ankle foot orthosis (AFO) within six weeks of stroke results in better balance outcomes and earlier independent ambulation than if AFO use is delayed, according to research from the Netherlands.
Investigators from Roessingh Research & Development in Enschede randomized 18 patients to receive AFOs at either the time of inclusion in the study (within six weeks of stroke) or eight weeks later. Both groups received the same rehabilitation, with a focus on balance and ambulation, the only difference being that the “late” group did the first eight weeks of rehabilitation without an AFO while the “early” group did all rehabilitation while wearing AFOs. Balance measures were assessed every two weeks for 16 weeks.
AFOs were prefabricated nonarticulated devices made from polypropylene in three different rigidities to accommodate a range of patient needs. Device fitting involved particular attention to the alignment of the AFO within the shoe and the alignment of the knee and hip, said Jaap Buurke, PT, PhD, scientific manager of the research cluster Restoration and Human Function at Roessingh Research & Development, who presented his group’s findings at the ISPO World Congress in Hyderabad on behalf of graduate student Corien Nikamp.
At follow up, both groups demonstrated significant improvement on the Berg Balance Scale and Functional Ambulation Categories balance tests, but improvements in the early AFO group were more pronounced and occurred earlier than in the late group. Early AFO users achieved independent ambulation earlier than those in the late group, and there was a trend toward better outcomes on the 10-m walk test, six-minute walk test, and Timed Up and Go test for the early group.
Previous research from the same Dutch institution suggests that improvement on functional balance tests with AFO use is not necessarily reflected in instrumented tests of dynamic balance. In a 2009 study published in Clinical Biomechanics, Buurke and colleagues found that 20 chronic stroke patients performed significantly better with AFOs than without on five functional balance tests but not on platform-based force plate tests of dynamic balance.
The current study addresses some limitations of the earlier one, Buurke said.
“In a cross-sectional study, the patients are almost always chronic stroke patients and the intervention often involves not providing the AFO but removing it,” he said.
In a separate study presented in Hyderabad, researchers from the University of Strathclyde in Glasgow, Scotland, used 3D motion analysis to assess the effect of polypropylene solid AFOs on gait mechanics in three patients, beginning within two months from stroke onset and continuing for six months.
Stephanos Solomonidis, BSc, CEng, FIMechE, senior lecturer in biomedical engineering at the university, and colleagues found that the AFOs improved joint kinematics in both the paretic and sound limbs, facilitated heel strike, and reduced toe drag during swing. In addition, one patient was analyzed wearing an instrumented AFO, which confirmed that the device reduced the net ankle moment by assisting the dorsiflexor muscles during the first half of stance phase.
Sources:
Nikamp C, Buurke J, Nederhand M, et al. Timing of ankle foot orthoses after stroke: First results of a randomized longitudinal study. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
Simons CD, van Asseldonk EH, van der Kooij H, et al. Ankle-foot orthoses in stroke: Effects on functional balance, weight-bearing asymmetry and the contribution of each lower limb to balance control. Clin Biomech 2009;24(9):769-775.
Papi E, Solomonidis S, Bowers R, Rowe P. Effect of ankle foot orthoses on gait biomechanics of early stroke patients. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
What appears to be idiopathic scoliosis may actually be functional scoliosis that can be effectively treated with foot orthoses in children who are hyperpronators, according to research from Chungnam National University in Daejeon, South Korea.
In 38 patients, investigators found that use of rigid foot orthoses combined with stretching and strengthening exercises significantly reduced pelvic height asymmetry from 8.7 mm at baseline to 5.8 mm at 12 months and 5.1 mm at 18 months.
“This may be misdiagnosed as idiopathic if not recognized while children are young,” said Bong-Ok Kim, MD, a researcher in the department of rehabilitation medicine at the university, who presented her group’s findings at the ISPO World Congress in Hyderabad. “Initially you might think this is just functional and you don’t have to treat it because it will just go straight when the kids get older. But that’s not necessarily true.”
All children had an initial Cobb angle greater than 10°, a pelvic height differential of 5 mm or greater, and a resting calcaneal stance position of at least 2° of eversion. Children with pure leg length discrepancies were excluded.
Children were encouraged to wear the orthoses with shoes during all outdoor activities, at school, and at home when not in bed—which can be a challenge in Korea, where shoes are not typically worn at home, Kim said.
“We encouraged parents to wear shoes in the house when their kids needed to be wearing the shoes,” she said. “We need to change the culture to improve compliance.”
Source:
Kim B, Chang I, Park I, Sim E. Effect of custom molded rigid foot orthosis on the functional lumbar scoliosis in children. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
Orthotic walkers have significant effects on proximal joint mechanics during gait, the extent of which appear to depend on individual device design, according to research from the University of Central Lancashire in the UK.
Investigators analyzed the kinetic and kinematic effects of two different orthotic walkers on hip and knee function in 11 healthy volunteers. The two devices differed from one another primarily with regard to positioning of the heel rocker and inclination of the tibial component: Device A featured a slightly more anterior heel rocker and a slightly anterior tibial inclination; Device P featured a slightly more posterior heel rocker and a slightly posterior tibial inclination.
Compared to walking in normal footwear, both walkers were associated with significantly greater knee flexion angle during stance phase, but only Device P was also associated with a significantly increased knee flexion moment. Knee extension moment was significantly higher for both rockers than for normal footwear, but was also significantly higher for Device P than for Device A.
At the hip, both walkers were associated with significantly greater hip extension angles and significantly decreased hip extension moments compared to normal footwear. In both cases, the deviations were more pronounced with Device P than Device A.
These effects are likely related to the relatively posterior positioning of the heel rocker and the posterior tibial inclination in Device P, said James Richards, BEng, MSc, PhD, professor of biomechanics at the University of Central Lancashire, who presented his group’s findings at the ISPO World Congress in Hyderabad, India.
The concept of an association between tibial inclination and gait mechanics was also discussed during several ISPO sessions by Elaine Owen, MSc, SRP, MCSP, superintendent and clinical specialist pediatric physiotherapist at the Child Development Centre in Bangor, North Wales, UK.
In her work with children with cerebral palsy, Owen consistently advocates that the shaft of an ankle foot orthosis be slightly inclined relative to vertical, with inclinations varying in degrees depending on the patient’s natural inclination, stiffness, and any observed shank reversal. Owen described these evidence-based concepts in a 2010 paper published in Prosthetics & Orthotics International.
“An optimal alignment is always one where they can incline the thigh,” Owen said. “It’s the inclined alignment that will give the optimal performance.”
Richards believes that similar biomechanical concepts may be at work with regard to the proximal effects of orthotic walkers.
“A better tibia inclination angle seems to be a dominant factor in knee and hip mechanics, although the rockers are also very important,” he said.
Richards emphasized, however, that manufacturers are constantly redesigning devices and probably have done so since the launch of his group’s study.
“The take-home message is that not all walkers are the same,” he said. “Further research is needed on the effects of orthotic walkers on knee and hip joint mechanics with a focus on the effects of changing the tibial angle and rocker profiles. This should help to inform future designs of walkers, with a greater focus on obtaining a more normal gait pattern.”
And, when it comes to at least one variable, an orthotic walker’s effect on the knee may actually be positive. The Central Lancashire group found that both devices were associated with significant reductions in knee adduction moment, which is commonly used as a surrogate for medial knee loading in studies of patients with medial compartment knee osteoarthritis, compared to normal footwear.
Source:
Richards J, Payne K, Myatt D, Chohan A. Do orthotic walkers affect knee and hip function during gait? Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
Owen E. The importance of being earnest about shank and thigh kinematics especially when using ankle-foot orthoses. Prosthet Orthot Int 2010;34(3):254-269.
Orthotic management of pediatric talipes planovalgus starting at an early age is associated with significant improvement in weightbearing arch structure, according to research from Saga University in Japan.
Investigators analyzed 102 children treated for talipes planovalgus starting from a mean age of 2 years 9 months. Children were given shoe inserts with arch supports, metatarsal pads, and lateral wedges ranging in height from 3 mm to 7 mm depending on the degree of valgus deformity. Parents were advised to have children wear the inserts with shoes with hard heel counters that could be firmly tied or otherwise fastened. The children were also prescribed exercises, including walking barefoot on unstable surfaces and walking on their tiptoes.
Children wore the inserts for a mean of three years, seven months. More than half (57.8%) of patients achieved a weightbearing longitudinal arch by the end of the treatment, compared to 2.9% at baseline. A similar improvement was seen with regard to the weightbearing transverse arch, improving from 2% of patients at baseline to 22.5% of patients after treatment.
Toyoko Asami, PhD, clinical professor in the department of rehabilitation medicine at Saga University who presented the group’s findings at the ISPO World Congress in Hyderabad, noted that there is still room for more improvement.
“After the orthotic treatment had been provided, more than 40% of children at an average age of six and a half still have talipes planovalgus, indicating the need for further management,” Asami said.
Source:
Asami T, Kodama K, Akiyama N, et al. Orthotic treatment using shoe inserts for talipes planovalgus in children. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
Research from Sweden and Egypt provides more evidence that foot orthoses can significantly decrease plantar pressures in patients with diabetes, theoretically reducing the risk of foot ulcers and lower extremity amputation.
Investigators from the University of Gothenberg in Sweden found that both custom and prefabricated insoles significantly reduced in-shoe plantar pressures in patients at risk of ulceration, effects that were maintained after one year. And researchers from Ain Shams University in Cairo, Egypt, also documented significant plantar pressure reductions with the use of a custom-molded foot orthosis in diabetic patients who had previously undergone first ray amputation.
The Swedish team randomized 114 diabetic patients to receive one of three types of insoles: a custom device made from 35-shore ethylene vinyl acetate (EVA), a custom insole made from 55-shore EVA, or a prefabricated device with support in the medial arch, a metatarsal pad, and a 25-shore A Poron cover. Patients wore the designated insoles with their own standard walking shoes. The researchers did not track patient compliance with insole wear.
No patient had an active foot ulcer at baseline; one patient developed an ulcer in the first six months, but that one case was the only ulcer to occur in the 12-month study period. Although the study did not include a control group, the ulceration rate of .9% was lower than most rates reported in the literature.
All three types of orthoses were associated with peak plantar pressures of less than 272 kPa after one year. Peak plantar pressures for the custom orthoses were significantly lower than for the prefabricated orthoses in the heel region only, said Ulla Tang, CPO, a doctoral student at the University of Gothenburg’s Institute of Clinical Sciences and an orthotist-prosthetist at Sahlgrenska University Hospital, who presented the findings at the ISPO World Congress in Hyderabad, India.
“All three types of inserts effectively distribute pressure under the sole in order to minimize the risk of ulcers,” Tang said.
The Egyptian group created custom foot orthoses for 20 patients with first ray amputations secondary to diabetic foot ulcers—a particularly challenging population with regard to preventing ulcer recurrence.
“Every foot after an amputation is usually abnormally shaped,” said Rana El-Hilaly, MD, a lecturer in rheumatology and rehabilitation at Ain Shams University, who presented her group’s findings in Hyderabad. “What I want is something that will fill in the defect and increase total contact area to better distribute the pressure. So I create the device for the foot as if it was a prosthetic socket, to capture the different shapes and bony prominences.”
Each custom orthosis included a 4-mm Pedillin base layer supplemented with Poron in high-pressure areas, topped with a layer of EVA and another layer of Pedillin.
El-Hilaly and colleagues assessed static and dynamic plantar pressures in the 20 patients using a pressure mat under three conditions: barefoot, with the custom orthoses, and with flat insoles. They found that, during walking, both insoles decreased peak plantar pressures in the midfoot, heel, and midmetatarsal regions, but the custom insoles decreased pressures more than the flat insoles. During standing, they found significant reduction of peak plantar pressures only with the custom insoles.
The findings were also e-published in December by The Foot.
Sources:
Tang U, Zugner R, Tranberg R. Effectiveness of insoles in preventive treatment of diabetic patients. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
El-Hilaly R, El-Shazly O, Amer A. The role of a total contact insole in diminishing foot pressures following first ray amputation in diabetics. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
El-Hilaly R, El-Shazly O, Amer A. The role of a total contact insole in diminishing foot pressures following partial first ray amputation in diabetic patients. Foot 2012 Dec 19. [Epub ahead of print]
A rocker bar proximally positioned on a running shoe can relieve tension on the Achilles tendon as well as reduce the force required of the calf muscles during walking and slow running, according to research from the Netherlands.
The findings could have implications for rehabilitation of runners with Achilles tendinosis, said Klaas Postema, MD, PhD, professor of rehabilitation medicine at the University of Groningen, who presented his group’s results at the ISPO World Congress in Hyderabad, India.
“With every step, there’s a lot of tension on the Achilles tendon. It’s not surprising that it hurts,” Postema said. “With a proximally placed rocker bar the ground reaction force moves proximally, and the lever arm is shorter, so the need for force from the calf muscles goes down.”
Postema and colleagues analyzed 16 recreational runners, all heel strikers, while walking and slow running (7 km/h) wearing a sport shoe with and without a rocker bar. At both speeds, the rocker-bar condition was associated with significant decreases in internal plantar flexion moment and ankle dorsiflexion motion during late stance. Spatiotemporal variables and hip and knee moments did not differ significantly between shoe conditions.
Source:
Postema K, Sobhani S, Vd Heuvel E, et al. A proximally placed rocker bar and external ankle moments during walking and slow speed running. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
A Taiwanese study offers more evidence that offloading knee braces and wedged foot orthoses are both associated with significant biomechanical improvements in patients with knee osteoarthritis (OA).
Investigators from National Taiwan University performed gait analysis on 15 patients with medial compartment knee OA and 15 matched controls. Knee OA patients were analyzed under two orthotic conditions, with a knee orthosis or with lateral wedged cork foot orthoses. Patients with severe pain were excluded.
Both orthotic conditions were associated with significant increases in gait speed, decreases in gait cycle time, and a lateral shift of the center of pressure compared to shoes only. Both significantly decreased peak knee adduction moment, which is commonly used as a surrogate measure for knee loading, as well as knee valgus angle and knee valgus excursion. Both devices, in particular the knee brace, were associated with a trend toward decreased cocontraction of the quadriceps and hamstrings muscles on the lateral side during gait.
The knee brace was associated with significant decreases in knee flexion angle and knee flexion excursion compared to shoes only. The wedged foot orthoses were associated with a slight increase in ankle abduction moment.
The findings are consistent with those of previous studies (see “OA knee braces face off against wedged insoles,” November 2012, page 37).
“Orthotic interventions can improve gait deviations and kinematic and kinetic performance,” said Chun-Te Lin, a doctoral student in the Rehabilitation Engineering Laboratory at National Taiwan University, who presented his group’s findings at the ISPO World Congress in Hyderabad, India.
Source:
Lin C, Chang L. The effects of foot orthoses and knee orthoses on gait pattern and muscular activation of patients with medial compartment knee osteoarthritis. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
Dynamic orthoses offer an effective alternative to static devices for management of tip-toe gait and knee flexion contracture in children with cerebral palsy (CP), particularly because the dynamic devices are associated with greater compliance, according to separate studies from Sweden and France.
In 10 children with CP, researchers from the Medical University of Vienna found that wearing a dynamic ankle foot orthosis (AFO) 23 hours a day was associated with significant correction of tip-toe walking after three months. The AFO, which features a ring-shaped foot support, was designed to address intra-articular rotational misalignment at the ankle, according to Christian Grasl, Dipl Ing, a researcher in the Center for Medical Physics and Biomedical Engineering at the Medical University of Vienna, who presented his group’s findings at the ISPO World Congress in Hyderabad.
Just one of the 10 children continued to walk with a primary forefoot strike after the three months of AFO wear. Mean ankle dorsiflexion and foot progression angle for the group improved, with no loss of ankle power.
Similar effects could probably be achieved with a less aggressive regimen, Grasl said, but the Vienna researchers actually believe the 23-hour number makes intuitive sense to children and parents.
“It may be that 17 or 18 hours is enough, but it’s just easier to say 23 hours, which leaves about one hour for bathing and cleaning the device,” he said.
In a second study from the Regional Institute for Physical Medicine and Rehabilitation in Nancy, France, researchers found that dynamic knee ankle foot orthoses (KAFOs) designed to provide a low-load prolonged stretch were more effective than static KAFOs for managing knee flexion contracture in children with CP.
Thirty children with knee flexion contracture of at least 10° were randomized to receive dynamic or static KAFOs. After eight months of night use, knee flexion contracture had been reduced by a mean of 12.5° with the dynamic KAFO compared to just 3.5° with the static KAFO. Device tolerance was good or very good in 72.5% of patients in the dynamic group but just 31.8% of the static group.
“The key for success is the wearing time of the brace, not the level of torque. The practitioner must explain this to the family,” said Isabelle Heymann, a researcher at the Regional Institute for Physical Medicine and Rehabilitation, who presented her group’s findings in Hyderabad.
A third study from the University of Gothenburg in Sweden found that gait abnormalities related to leg length discrepancies (LLD) in children with CP can be addressed by adding an extra sole to the shoe of the shorter limb.
In eight children with a mean LLD of 1.73 cm, researchers added a split sole of 55-shore ethylene vinyl acetate (EVA) to the shoe of the shorter limb and compared spatiotemporal gait variables for that condition with two others, barefoot and unadjusted shoes only.
The extra-sole condition was the only one of the three in which percent of time in stance phase did not differ significantly between limbs, according to Roland Zugner, RPT, MSc, a doctoral student in the department of orthopedics at the University of Gothenburg, who presented the results in Hyderabad.
Sources:
Grasl C, Kranzl A, Csepan R. Outcome of 23H bracing for tip-toe walking children with cerebral palsy. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
Heymann I. Superior efficacy of low-load prolonged stretch dynamic orthosis in cerebral palsy. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
Zugner R, Stefansdottir I, Nystrom-Eek M. Gait pattern in children with CP and leg length discrepancy, effects of an extra sole. Presented at International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
Lower extremity practitioners were among the first responders after two explosions ravaged the Boston Marathon last month, and are continuing to help heal the hundreds of victims who lost limbs or experienced other traumatic lower extremity injuries.
By Emily Delzell
Lower extremity clinicians helped save lives at the April 15 Boston Marathon bombings, which killed three and injured 264, and now are at victims’ sides as they begin to recover.
Podiatrist Kirk Neustrom, DPM, was back in Boston for his 19th year as a volunteer in the marathon’s medical tent, which was located just around the corner from the finish line. The day had brought perfect running conditions and the healthcare professionals inside the tent were dealing at a relaxed pace with the routine injuries—blisters, cramping, tendinitis, potential stress fractures—that go along with running more than 26 miles.
Neustrom, a former marathoner who gave up the long races after completing the 100th Boston marathon 17 years ago, was thrilled to be back in the city.
“I did an externship at Cambridge Hospital in 1985 and fell in love with Boston,” said Neustrom, who practices in Des Moines, IW. “I look forward every year to going back. As some people have said, Boston is one of the happiest places on the planet that day—it’s a holiday, the Red Sox are always in, the race begins in Hopkinton and comes into Boston with people celebrating all the way—it’s just an awesome place to be.”
Neustrom had just finished helping a runner with some minor issues—the man, a soldier in the US Army, had run the race in full fatigues complete with boots and was dealing with some blisters—and was heading out of the tent toward the finish line with a friend so they could watch the runners come in and “slap some high fives.”
To Neustrom, the first explosion sounded like a cannon. He had a few seconds to wonder who might be shooting off a cannon and why, and then the second explosion went off.
“I knew then what had happened and took off in the direction of the finish line; I knew there would be injuries, casualties,” he said.
First responders
Neustrom arrived at the scene of the first bomb 30 or 40 seconds after the explosion.
“There were already first responders there getting people into wheelchairs and I started triaging people, addressing injuries, talking to victims to help calm them down,” he said.
Lyle Micheli, MD, was among those first responders. The orthopedic surgeon was at the finish line when the first bomb exploded, directing the advance medical team that is positioned to help exhausted or injured runners as they cross the finish line.
This year the finish line medical team, which Micheli has directed since 1978, included five physicians, 12 athletic trainers, and more than 20 students manning wheelchairs for quick transport of runners to the fully equipped medical tent.
“After the second bomb went off, a group of us ran toward the barrier between the street and spectators and started to tear it down. I could see people lying on the sidewalk,” Micheli said.
With most of the medical supplies in the tent some 50 yards away, Micheli and others began improvising. A store that sold running gear was in front of them and they went in, pulling shirts off racks and using them to pack wounds. Micheli made a tourniquet out of a running jacket for a victim who had lost part of a leg, using part of a coat hanger to twist it tightly onto the residual aspect of the injured limb.
“People were just pitching in. I saw a number of makeshift tourniquets, several belts used as tourniquets,” he said. “Victims with traumatic amputations were put into the wheelchairs and the kids were racing them down to the medical tent, where they’d set up a triage system and were quickly getting people treated and transported to various hospitals.”
Neustrom noted that while the scene was chaotic and urgent, it was also quiet.
“There was no screaming, no yelling, not really from the victims or the responders. Everyone was professional, doing their job,” he said. “The only voices you’d hear were occasional shouts for a backboard or some gauze or something.”
Micheli was also struck by the largely silent scene of rapid response amid the violent traumatic injuries, most of which were to the lower extremities.
“There was one young woman with her leg pretty well opened up, and in five minutes or so we had her wound packed, inserted an IV, applied a splint, and carried her cot down to the triage area. That was pretty typical of what happened,” said Micheli, who is director of the Division of Sports Medicine at Boston Children’s Hospital and clinical professor of orthopaedic surgery at Harvard Medical School.
John Cowin, MD, an orthopedic surgeon from Lake County, FL, was at the race with his family to watch his daughter complete her third Boston Marathon, which she has run each year since her breast cancer diagnosis to raise funds for research. Cowin was on the east side of Boylston Street when the second explosion went off just across from him. He and some other spectators crossed their barrier to the opposite side of the street to try and aid the injured.
“There was blood everywhere,” said Cowin. “There was a guy lying on the ground with his foot mostly gone, held on by maybe three tendons. Next to him was a stroller with a three year old, his son, and the father’s major worry was his son. I went over and picked the boy up—he had a scalp laceration—and held onto to him to help calm him down, but then it occurred to me that are were other people with worse injuries and I can’t spend time like this. So I handed the child to a policeman and moved on.”
Cowin aided other victims, including Lu Lingzi, a Boston University graduate student from China who was one of the three spectators who died that day. He also witnessed the mother of a dead boy, later identified as 8-year-old Martin Richard, asking for a few more minutes to hold her son’s body before she was loaded into an ambulance.
A family member of the injured father-and-son pair later contacted Cowin; she wanted to return his belt, which had been used as a tourniquet. Cowin asked for a picture of the injured boy and the woman told him the child had appeared on the cover of a special tablet edition of Time magazine.
Neustrom, Micheli, and Cowin all said that the close proximity of hundreds of fast-acting medical staff, police, fire department personnel, and other first responders to the explosion sites saved many lives that day.
“If the bombs had gone off six blocks further down, we would have had many more fatalities,” Micheli said. “We already had a system of getting injured people—though not badly injured people—to the medical tent and triaging them. We’ve worked this system for 20 years and it worked pretty well, though this time we had very different people in the wheelchairs.”
Ambulances backed up the medical tent, transporting victims to nearby hospitals, which include six major trauma centers—one for children and five for adults—all within a mile or so of the blasts. The explosions occurred a few minutes before the 3 pm shift change common in area hospitals, many of which were working with reduced surgical schedules because of the Patriot’s Day holiday, and, when patients began arriving just minutes after the explosions, two shifts of medical staff were on hand to provide care.
“We were able to get the most serious injuries on the road to the hospital pretty quickly, and from what I heard, they got them into the ORs quickly—and that’s the key, of course,” Micheli said.
All injured victims who made it to Boston’s hospitals survived.
Cowin, who has treated many orthopedic injuries in his 30-plus years as a surgeon, said he had never seen the kind of explosive trauma he treated that day.
“I was surprised at how much the scene affected me. I finally wrote about it and posted it on Facebook, and the writing lifted a tremendous burden,” he said.
Recovery
Two weeks after the bombing, medical teams caring for victims were focused on wound healing and other care to maximize patients’ chances for the best possible recovery. Many of the seriously injured had endured multiple surgeries, including 14 who had undergone lower extremity amputation.
“The biggest priority right now is wound healing and shaping of the residual limbs. The surgeons have been very careful in their surgical plans to provide the best limb they can surgically, which helps with the success of using a prosthesis,” said Linda Arslanian, PT, DPT, MS, director of rehabilitation services at Brigham and Women’s Hospital.
“With traumatic amputations, this work is usually done in stages—they rarely do the definitive amputation right away. The goal is achieving the optimal residual limb, one that is well-shaped, symmetrical, and very vascular and that will heal with minimal scarring and diminish the potential for neuromas to form or other complications that make prosthetic use less well-tolerated,” Arslanian said.
At Spaulding Rehabilitation Hospital, Advanced Clinician Lisa Pratt, MSPT, was also working with victims in the early stage of recovery.
“We’re doing things like teaching patients about phantom sensations and postsurgical pain, working on range of motion and strength, both of their lower extremities as well as their core and their upper body—it’s a comprehensive approach to building and regaining strength after trauma and hospitalization,” Pratt said.
Patients were also learning about positioning and pressure relief, the importance of skin care and skin integrity during the healing process, edema management, and mobility, she said.
“We’re also talking with them about discharge planning, and we’re working with them to address their goals and assist them in returning back to their traditional activities and all the things they want to get back to doing,” said Pratt, who works with traumatic amputees during the preprosthetic phase of recovery as well as in Spaulding’s limb loss amputee clinic.
Arslanian noted that, although these injuries are not physically different from other traumatic amputations that occur in high-velocity settings, the circumstances under which they occurred mean patients’ psychological reactions are highly variable, and all are at different emotional stages.
Some want to talk to other amputees. Jason Rizzo, CPO, director of prosthetics for Rogerson Orthopedic, an 80-year-old family practice in South Boston, arranged a peer visit for one victim who was trying to decide whether to try and salvage her injured limbs or go ahead with amputations.
“I was told she wanted to speak with an amputee of similar function and the level at which she’d be amputated. One of our high-level amputees is a triathlete and she talked with him. They had a long session and he spoke with her family as well. They had a lot of questions,” said Rizzo, who noted he was told the visit helped the patient decide on amputation.
Rizzo and other lower extremity clinicians are working with local and national organizations, such as the American Orthotic & Prosthetic Association (AOPA), to make sure all victims, especially the uninsured and underinsured, will have access to the artificial limbs and mobility assistive devices they need. (To find out how you can help, contact AOPA staff member Steve Custer at scuster@ aopanet.org or 571/431-0876.)
Arslanian, who has been working with traumatic amputees for more than 30 years, noted medical advancements, while bought at the high cost of wars in Iraq and Afghanistan, will make a big difference in outcomes for these patients.
“There are possibilities that exist now for saving patients with traumatic dismemberment and preserving soft tissues to optimize prosthetic use; also, prosthetics and rehabilitation far exceed what they used to be,” she said. “There are a lot of positive things that can happen here. Fortunately, I think these patients will get the best possible care they can get and will restore their lives to their maximum potential.”
