Physical Therapy in Oakland for Pediatric
When it comes to the nonoperative (Ponseti) treatment of clubfoot in children, does it matter if a Physical Therapist manages care versus the orthopedic surgeon? According to this study, quality of care improved when directed by the Physical Therapist compared to the surgeon. If this proves true in general, it could free surgeons up to do more of the technical surgical work they are trained for. Delivery of care for clubfoot could be left up to Physical Therapists, nurse practitioners, and physician assistants.
Clubfoot is a congenital (present at birth) deformity that causes the feet to point down and turn inwards. Left untreated, this condition prevents normal foot and ankle motion needed for walking and running. The Ponseti method developed by Dr. I. Ponseti was first tried 50 years ago. Since that time, it has been proven effective and is used around the world.
The method involves gentle manipulations of the feet and casting. The treatment is based on an accurate understanding of the functional anatomy of the foot and of the biological responses possible in the musculoskeletal system. Muscles, ligaments and bones respond in six to eight weeks to corrective position changes gradually obtained by manipulation and casting.
Manipulation and casting refers to moving the bones through the full available motion and then putting a cast on the foot, ankle, and lower leg to hold them in place. Once the soft tissues and bones get used to that position, the cast is removed and the foot and ankle are manipulated (moved) a little further, again putting a cast on to maintain the new position. This process is repeated each week until the deformity is overcome.
This method has made it possible to move from a surgical to nonsurgical treatment with faster results and fewer complications. Years ago, extensive surgery was done to restructure the foot and ankle. This change in treatment is good news in countries like Canada and the United States because it can reduce the cost of health care for this problem. But it's even better news for undeveloped countries where there are few (sometimes no) specialists.
In this study, the results of 25 children treated by surgeons using the Ponseti method were compared with 95 children treated by Physical Therapists trained to use the same approach. Each child in both groups was placed in a semirigid fiberglass cast, which was removed (and replaced) weekly.
With each cast removal, the foot position was corrected as close to neutral (normal) as possible before reapplying another cast. This was repeated until the forefoot could be moved away from the midline at least 70 degrees. The hindfoot was also being corrected making it possible to move the calcaneus (heel bone) inward, a motion needed for normal walking.
If the hindfoot did not correct fully, the surgeon performed a percutaneous tenotomy. This is a release of the Achilles tendon through the skin without doing open surgery. After casting and/or tenotomy, the next step was to place the child in a Denis-Browne splint.
This orthotic has a pair of open-toed shoes attached to a bar. The shoes are placed at an angle to hold the correction. The shoe on the corrected side is placed at 70-degrees of external rotation. If the child had bilateral clubfeet (both sides involved), then both shoes were set at this angle. If only one foot was affected, the uninvolved shoe was placed at a 45-degree angle.
Parent/family education is a key element of the Ponseti method. Once the child is in a removable brace of this type, compliance is very important. For best results, the child must wear the Denis-Browne brace everyday (full-time, day and night) for three months.
After that, it can be removed during the day and just put on during naps and nighttime. But this schedule must be kept up until the child is four years old. The family must also bring the child to the clinic on a regular basis for follow-up. This is especially important as the bones of the foot (and the child) grow larger. The examiner can make any adjustments needed or resize the brace as the child grows and changes.
Success or failure? Which group did better? Treatment success was defined as a straight foot that could be put flat on the ground or floor when walking. The child could wear a regular shoe comfortably and use a heel-toe gait (walking) pattern. The final outcome also included at least 10 degrees of ankle dorsiflexion with the knee straight. Dorsiflexion refers to motion at the ankle that pulls the toes toward the face.
Failure occurred when the child's foot could not be fully corrected using the Ponseti treatment. Somewhere between success and failure was recurrence. In these cases, the Ponseti method worked but the correction was not maintained. The child ended up needing another series of casts and/or surgery to get back the good results originally obtained with treatment.
Besides rating each case as a success or failure, data was collected on the number of casts used to achieve normal alignment, the number of children who needed an Achilles tenotomy, and the rate of recurrence and/or need for another surgery. There was no difference between the groups in terms of number of casts used, number of Achilles tenotomies, or the failure rate.
However, the group treated by Physical Therapists had a significantly lower recurrence rate and fewer repeat Achilles tenotomies required. When recurrence did occur, it happened earlier in the course of treatment in the therapist-directed group. This made it possible to redirect treatment sooner. Most of the time, repeat cast treatment was all that the children needed for a successful recovery.
Statistical analysis also showed that children under the care of the Physical Therapist were less likely to have a recurrence during the two years of follow-up. And fewer children in the Physical Therapist group required additional surgical procedures.
The authors have set up a clubfoot clinic at their hospital run by Physical Therapists specially trained by the orthopaedic surgeons to treat children with clubfoot deformity. Although the surgeon makes the initial assessment, the therapist directs and carries out the treatment. The use of fiberglass tape to make the casts instead of plaster saves time and doesn't negatively affect the final results. The parents remove the cast and bathe the child the morning of their follow-up appointment.
Physical Therapists with their knowledge of anatomy and mobilization skills can learn the Ponseti manipulation and casting technique for clubfoot deformity. Some hands-on training and direct supervision will be needed at first. By having all children in a wide regional area come to the same clinic, the therapists gain the experience needed to provide expert care for this problem.
One other advantage of the Physical Therapist-directed program reported by the authors was the improved communication between parents and therapists. Parents were able to telephone or email the therapist with any questions or problems.
Patients got in to see the therapist right away when any problems developed. This was very helpful for families with children who just couldn't tolerate wearing the foot brace at night. Early communication made it possible to head off any problems and make the treatment more tolerable for the child. This factor may be what led to the improved results in the therapist-directed group. Data was not collected on this aspect of treatment, so future studies are needed to find the most effective way(s) to improve patient/family compliance.
Reference: Joseph A. Janicki, MD, et al. Comparison of Surgeon and Physical Therapist-Directed Ponseti Treatment of Idiopathic Clubfoot. In The Journal of Bone and Joint Surgery. May 2009. Vol. 91. No. 5. Pp. 1101-1108.
Taylor and Thornburg Physical Therapy, Inc. provides services for Physical Therapy in Oakland.