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Evidence based treatment protocol for use of gait plates

Discussion in 'Pediatrics' started by Foot Doc, Mar 7, 2009.

  1. Foot Doc

    Foot Doc Active Member


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    Hi everyone,

    Can anyone guide me in the right direction regarding the evidence based treatment protocol for the use of gait plates?

    Specifically, what age is appropriate to prescribe the device (safely) and what age will the device no longer be of any benifit or be of detriment to the Pt?

    I understand that there are many other treatment modalities that are used alongside the gait plate to treat the intoeing child, however, i am unable to find any real evidnce based protocol for their use.

    Cheers,

    FD
     
  2. Nina Davies

    Nina Davies Member

    Hi,

    I think the first question you have to ask before writing your protocol is why are you wanting to use them?

    Intoeing is a normal variant especially in the younger years, as children get older again it is not as common but not necessarily something of concern. The tibia's milestone is 10 and the femur's c.14 and any unwinding will occur with growth, not over night. Therefore in a protocol you can't just say 'for intoeing'.

    So I will take it that a full assessment has taken place (including neuro) and torsion is the cause...

    Orthotics or gait plates cannot affect this rotation because it is a bony change. Gait plates can affect the cosmesis but should we treat on these grounds?..and I would say no for the following reasons...

    It is a normal variant (but if they are symptomatic/ appear in pain, look for something else Sever's patients commonly intoe to avoid pain etc)

    There is a paucity of research A. Redmond in 2000 published a paper in JAPMA saying that more research was needed and only the cosmesis was improved.

    Bones develop relying on natural forces and to date we still do not know what our interventions cause in this field and for those reasons cosmesis alone is not a reason to intervene.

    There is no research on the effects gait plates have on the knee moments...and if this was done then we would be a lot clearer on their true effects.

    In the end we know that gait plates improve cosmesis and with that comes less tripping...only in severe cases would I consider gait plates in that the child was tripping to the point that it would cause them considerable injury if not treated. To give a ball park figure, if you seeing a good mix of adults and children, you would precribe one every 10 years.

    If you do prescribe, parents/guardians should be given full advice on what you are doing, and that if any pain occurs (including the knee and back) for them to remove and most of all if they do not appear to be working - remove them!

    Looking at a lot of the paed posts people talk quite candidly about parents having concerns, of which you have to agree at times....one of the hardest things to do it treat the parent. In view of intoeing concerns and gait plates never treat the parent...there is certainly no research for this.

    To end with a story...I have 'a patient' coming in who has been seen by the paediatric specialist physiotherapist and the paediatric orthopaedic consultant, both have told her this is part of normal development...the mother (not patient) has left in floods of tears on both occasions...now being referred to me (possibly for 3rd time lucky)...despite not seeing this case yet I have to ask myself, does the mother want something to be wrong with her child or does she just not understand? I have a 1/2 a skeleton on standby to demonstrate and fingers crossed it works!

    Anyway, hope that helps!

    Nina :)
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. David Smith

    David Smith Well-Known Member

    Excellent post you seem to have deep knowledge of paediatric podiatry Nina. You have a nice clear writing style and should write more often to Pod Arena. (Please)

    all the best Dave
     
  5. Nina:

    Nice posting, Nina. However, I can't agree with just brushing off these young children's gait abnormalities as "normal variants". I also can't agree with just telling parents there is nothing you can do about it and their deformity is somehow "normal" is the best thing for the child or parents. Since when has intoeing been considered to be "normal" in the early walking child? What is the criteria you use to classify an angular deformity of a bone or joint as a "normal variant"? Are the clinicians that call intoeing in children a "normal variant" the same clinicians that call a child with a 6 degree everted RCSP with no medial longitudinal arch in a 5 year old also a "normal variant"?
     
  6. Nina Davies

    Nina Davies Member

    Hi,

    I accept that defining normal is not so simple in paediatrics as this will change with age nor will I assume everything is normal. Each child needs an individual assessment. The post was asking about gait plates and therefore that's what I was concentrating on!

    'Normal' has been outlined in Stahelli's work on rotational profiling and Jacquemier (2008, Gait and Posture) using asymptomatic subjects; from the results it is clear that there is a lot of variance. Valmassey outlines the normal heel position 0-7 years - quite a task when torsions, ossification and tissue structures are 'young'...these are just a few.

    What is not normal are the red flags related to orthopaedics, rheumatology, neurology etc; limp, pain, loss of function, the controversial 'end range', Gowers sign, abnormal shoe wear, bruising, instability...

    In the end, we can affect reducible problems such as tight structures, but we can't affect torsion with gait plates or other orthotics (to the point that we know what we are doing)...can we???

    Nina :)
     
  7. Nina:

    You used the term "normal variant" to describe intoeing in children which implies that intoeing in children should be considered be a form of normal development. I don't agree with the term "normal variant", don't agree what this clinical assessment means for the patient and parent, and basically don't agree with the whole philosophy, which is so prevalent in the orthopedic and pediatric medical communities, of minimizing gait abnormalities in children . Intoeing in children is not normal.

    My guess is that in a government funded health care system or in a health maintenance organization medical system, where there is a finite amount of money in the system and where the object is to treat as little as possible to save money for the organization, the term "normal variant" is used much more frequently by the clinicians treating within that system to describe intoeing in children than would be used in an optimal health care delivery system where the goal is to optimize the function of the child, prevent future problems for the child as they mature into adults and try to eliminate the child's pain with activities to ensure their physical and mental health, regardless of cost.

    When I see children, [I was trained personally by Ron Valmassy since he was my residency director during my Biomechanics Fellowship at CCPM from 25 years ago] I never call intoeing a "normal variant". During my training with Dr. Valmassy, intoeing was considered to be abnormal at any age. Depending on the age of the child and severity, we would do what we could for the child and parent from simple observation over time, to night splints, to gait plates, to make sure that the gait function of the child was optimized, they were having no problems as a result of our treatment and the parents understood exactly what we could and couldn't do with our treatment. We did not simply tell the parent, "don't worry, intoeing is a normal variant and they will eventually grow out of it" as many of our orthopedic colleagues and pediatrician colleagues so often like to tell the parents of these children.

    These types of discussions regarding the treatment of musculoskeletal complaints in children are vitally important since it is my sincere belief that most of the medical profession ignores many of the musculoskeletal complaints and more subtle musculoskeletal pathologies of children and likes to write them off as "normal variants" or "growing pains" (see Angela Evans' outstanding work in dispelling the myth of "growing pains"). These clinicians simply don't know how to recognize these pathologies, don't know what normal and abnormal gait is in children, and don't what to do for them if they were even have the clinical skills to be able to diagnose them. A good pediatric podiatrist specialist does know what to do for these children and their parents, and parents are very grateful to these practitioners who simply don't always write off these patients and parents as complaining about something they shouldn't be worried about.
     
  8. Nina Davies

    Nina Davies Member

    Kevin,

    Returning to the treatment of in-toeing, I am interested on how you would address a torsional issue. From reading current literature, I was under the impression that there was no evidence base to support the use of gait plates and that night splints were no longer favoured to physically correct in-toeing.

    As a clinician I am keen to work according to evidenced based practice, providing treatment on the grounds of effectiveness, safety and measurable outcomes. I would not deny treatment on the grounds of cost nor be ignorant to the long term implications of not intervening or parental concerns.

    I do hope this next point will not bring up subsequent threads “normal variant” undoubtedly will haunt me for the rest of this post! However I have to say that we are taught this along with torsional development -rightly or wrongly- and the literature does highlight variance (and therefore appearance).

    And on a final note, I agree that it is good to see papers from people such as Angela Evans who highlight issues in paediatrics and to those who provide thought, debate and support.

    Thank-you
    Nina
     
  9. Nina:

    I don't mean to beat you up on your use of the term "normal variant", but I have been around this stump many times before with podiatrists and other health professionals on the subject of when and not to treat pediatric foot and gait abnormalities. You may want to check out my chapter with Don Green that we wrote over 17 years ago on the subject of children's flatfoot and whether this condition, which many pediatricians consider a "normal variant" should be treated or not (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992).

    I am wondering, Nina, do you limit your treatments to only ones with "evidence base"? I'm all for having more research to back up what I do, but only approximately half of what I do and treat as a podiatrist has even a small amount of weak evidence to support that it works. The other half of the treatments I use have very little to no evidence to back them up, but I have no problem filling my clinic with patients who want me to treat them with my "no evidence treatments" so I can make their pain go away and make them walk and run better. My patients don't seem to like it when I tell them there is nothing that can be done for them. I try to find ways to help them, whether or not there is "evidence" to back up what I do for them.

    Unfortunately, as you may have noted, you have touched on two of my sensitive nerves with using the term "normal variant" and with your desire to "work according to evidenced based practice, providing treatment on the grounds of effectiveness, safety and measurable outcomes". I'll now answer your questions and I applaud you for hanging in there to carry on this very good discussion with me.

    I still use gait plates, but not frequently, to treat abnormal intoeing in children. They seem to decrease the intoe angle of gait, seem to be well tolerated and have not caused any problems in the children I have used them on over the past quarter century. I also use night splints in children, not to try and twist the bones of the child, but to help prevent the child from reinforcing their intoeing deformity during sleep. In much the same way that a plantar fasciitis night splint works to stretch the plantar fascia by the known viscoelastic phenomonon of the creep response, night splints for intoeing probably also help stretch out the hip ligaments so that there is less work required by the child to walk in a rectus manner versus an intoed manner. These splints do seem to work to some extent and certainly will do no harm to the child if applied correctly.

    I also spend a lot of time educating the parents of these children to have them sit cross-legged style to help stretch out the hip ligaments. I encourage large riding toys in younger children where the child will straddle the toy to externally rotate the hips and feet to ride them properly and will encourage in line skating, roller skating and/or ice skating in older children as a way for them to help encourage external foot and hip rotation. Nearly all of these treatments I am telling you about I learned personally from practicing with Dr. Ron Valmassy during my student and biomechanics fellowship years.

    Do any of these treatment methods have research evidence of their effectiveness? Not to my knowledge. However, do the children seem to improve more over time when these treatment methods are utilized along with proper patient/parent education? Definitely. Maybe when I am long gone from this world the research evidence that shows that what I have done for my patients for the last quarter century in making them walk and run better and make their pain go away will finally arrive....however, I'm not willing to make my patients continue to suffer in pain or continue to experience gait difficulties while I am waiting on "research evidence" to support what I do on a daily basis to help their pathologies.
     
  10. Graham

    Graham RIP

    Kevin,

    The question here is would they have improved over time without an intervention?
    I also beleive NINA was reffering more to the Non-Symptomatic child and the psycho-symptomatic parent.

    "Normal Variant" to me refers to what could reasonable fall within the standard deviation of the population. Of course, what is "Normal" may not be "ideal" considering the man made enviroment we are tossed in to!
     
  11. Many a loving parent has become what you call a "psycho-symptomatic parent" when confronted by a clinician that tells them that their child with an obvious foot and lower extremity deformity/abnormality just has a form of a "normal" deformity, that there is nothing to worry about, and that they will grow out of it. As both a parent, and grandparent, I have great empathy for parents and what they go through when trying to get the best of medical care available for their children and grandchildren.
     
  12. Graham

    Graham RIP

    Kevin,

    The dificulty we have is, is the foot structure they have actually a "deformity" or meerly a growth variation of what will become a relatively well functioning foot. After all, if we took a standard deviation of the adult poulation we would see the spectrum from very high to very flat. We only see, I would guess 1%or 2% of the poulation in our clinics. So there has to be more to the assumption that the flat foot is a "problem".

    I don't refer to the foot as a "deformity". Therfore will not sow that seed with the parent. As long as the child is active and pain free I will often suggest a yearly check up or a self referral should symptoms arise.

    Regards
     
  13. Graham:

    I basically agree with your assessment and the philosophy you have expressed above. However, we must also be empathetic to the parent and make every attempt to improve the child's physical situation both functionally and developmentally. It is my firm belief that we, as the experts in pediatric foot and lower extremity mechanical pathologies, are ultimately responsible for the care of these young people. Therefore, we need to be proactive with children and their treatment since the first 7 years of life are the "golden years of treatment opportunity".

    By "golden years of treatment opportunity" I mean that this is the only period within the life of an individual where permanent structural changes in the osseous segments of the foot and lower extremity may be relatively easily obtained with changes in the internal osseous stresses with treatments such as foot orthoses, braces and therapeutic exercises (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992). It is up to the clinician to know what the normal developmental patterns of the child are and make the clinical decision as whether to treat or not to treat the child with obvious abnormalities in their foot and lower extremity structure.

    Graham and Nina, I guess it all comes down to your definition of normal and abnormal. Is an intoed gait pattern in a child normal or abnormal? It has to be one or the other, since it can't be both. I say intoeing in a child is abnormal, and it sounds like both of you think it is normal??
     
  14. Graham

    Graham RIP

    Kevin,

    My concern here is you are practicing what sociologists call " a self fullfilling profecy". We don't have any idea what, if any, long term structural changes we can make with orthoses, and what the possible detrimental effects these may have in later life.


    Speaking for myself, there appears to be, with in the standard deviation of "normal" an number of children who show a moderate in toe gait at some point only to grow out of this as they mature. However, marked in toe gait with obvious awkward gait characteristics I would consider outside the "norm" and would treat earlier.

    regards
     
  15. Graham:

    Using your logic, then the medial heel skive and Howard's kinetic wedge would also be "self fulfilling prophesies", since we don't have any research evidence showing what long term structural changes we make using the technique or what possible detrimental effects these techniques may have in later life.

    What period in the life of an individual, then Graham, would you think that the clinician has the greatest potential to be able to exert external forces on the foot and lower extremity of the individual to effect permanent changes in the structure of their skeleton: 1) 0-10 yrs, 10-20 yrs, 20-30 yrs, 30-40 yrs, 40-50 yrs, 50-60 yrs, 60-70 yrs, 70-80 yrs? What do the sociologists say about that??:bang:
     
  16. Graham

    Graham RIP

    Kevin,

    Not at all. I use both these techniques, applying the reasoned hypotheses of both, to treat symptomatic, ie: painful, presentations. I do not assume that an asymptomatic child will become symptomatic if I do not treat them with an orthoses. I do this because we do not know this. We know, reasonably, that when applying whatever biomajic we practice to an orthoses to treat a symptomatic client that there is likely to be a beneficial effect in relation to the resolution of their pain.


    I do not believe that an Orthoses will apply enough force at any age to effect permanent changes. We know that serial casting and chines bound feet etc when applied over long periods will change bony structures in the growing child. Personally I haven't tried this!:confused:

    We need to treat symptoms with the appropriate application of a therapy based on the evidence and theroretical developments we have at hand. We do not have the evidence to or the ehical right to treat an asymptomatic child just because we "believe" we should. After all, we treat to help - if it an't broke...don't fix it.

    regards
     
  17. Graham:

    Here is where we differ. I do believe that by correct application of orthosis reaction forces within the child's foot we can not only alter the patterns of internal stresses within the foot skeleton of the child but also, over time, alter the growth patterns of the developing osseous segments of the child's foot so that their adult foot shape will be improve. If serial casting works, then why can't foot orthoses also work. Both serial casting and foot orthoses are using the same biomechanics and orthopedic principles to cause positive changes in the child's skeleton: applying external forces to the skeleton of the child to cause permanent structural changes to their foot and/or lower extremity.

    As far as "ethical rights", my opinion is that we have the ethical right and responsibilty to treat these children with the best treatments available, using the best biomechanics knowledge available, while monitoring these children over the course of our treatments to ensure that no abnormal pathologies are occurring. What I find to be "unethical" are those clinicians that tell the parent there is nothing that can be done for their child's condition, that their child's condition is normal, with the clinician sitting on their hands doing nothing positive for the child, ultimately dooming these children to a future of diminished functionality as an adult. I guess we just have a different view of what ethical behavior is for clinicians treating children.
     
  18. Graham

    Graham RIP

    Kevin,

    I believe this discussion deserves a thread of it's own

    regards
     
  19. Graham:

    Poor Nina. I've probably driven her into hiding by now, never wanting to use those words "normal variant" again. ;)
     
    Last edited: Mar 10, 2009
  20. Nina Davies

    Nina Davies Member

    Hiding? Here I am!...Just watching different feathers fly! Thank-you for joining in..and I do hope it's safe to come out from my rock.

    I really have a problem with HOW orthoses affect growing bones, in particular gait plates, that's why I responded.

    I understand the benefits we can have with sitting postions and skating etc. and dare I say there is evidence or at least similarities to support this, so no you wouldn't just leave this out of treatment options and package your patients off....anyway....

    A year ago I read H. Frost's theories/ papers on bone adaptation (who is not a podiatrists and is moving on from Wolff) and after it all I just thought, what the heck are we doing, mechanical issues are the tip of the iceberg when it comes to bone development.

    So, without going into wrangles about prevalance and treatment, it's good to take a step back. To outline the paradigm, if you're not already aquainted with it:

    1. Mechanical forces on skeletons generate signals in skeletal organs that control the biologic mechanisms that determine the architecture and strength of those organs.
    2. These occur in ways that let the organs endure their voluntary mechanical usage for life without hurting or breaking.
    3. To work properly, these mechanisms need non-mechanical factors (hormones, vitamins, calcium, genes, cytokines, etc.).
    4. Only mechanical factors can guide those mechanisms in time and anatomical space.
    5. This arrangement determines skeletal health and disorders can cause or help to cause numerous disorders of skeletal and extra-skeletal organs (the collagenous tissue in ligaments and tendons also forms a part of extra-skeletal organs).

    and a quote

    “The function of the skeleton is not purely mechanical, and therefore its mass and morphology represent a compromise between different physiological demands, of which mechanical competence is only one”. (Ruff et al, 2006)

    Food for thought and something for another thread perhaps.

    Thank-you

    Nina :)

    Ps Anyway never mind about me, where's the original poster gone?!!
     
  21. Foot Doc

    Foot Doc Active Member

    Hi all,
    Im still here. And before i go on i just want to say thank you (and to everyone else) for posting and answering my question. Just reading all the interesting posts regarding the subject.
    I guess its taken off on a bit of a tangent...........but its still very interesting to read.
    My main query has to some extent been answered. I wanted to know what age is appropraite to issue a gait plate and what age would be of no use.
    Basicly, how old is old enough and how old is too old? This is taking in to consideration that all the appropriate tests and exams have been done and there is no neurological, compensatory, etc cause.
    Once again, thank you.

    FD
     
  22. Bug

    Bug Well-Known Member

    What a lovely read thus far.

    I do think however prior to the treatment the establishment of causality is imperative. The treatment of internal hip positioning from a child that W sits, has low tone, poor spacial awareness etc with gait plates might make the child walk straighter however when they are out, the child still has tight internal rotators, poor core strength and w sits because they are closer to the ground when they are playing therefore won't fall over.

    Then there is metadductus, what will a gait plate do there? It's not going to fix that curvy little foot.

    I'll admit I am not a fan of gait plates and by their design I am wary of their use with such flexible and moldable bones. I think tibial torsion is most prominent under 2 and the wait and see option with sleep positions/sitting monitoring is the best approach. Like Kevin, if there are external factors influencing these then to address those with night splints etc.

    If femoral torsion/anterversion, really, what are we going to do about that from forcing out the foot? Restricted musculature at the hips? Then stretch and strength work. Metadductus, cast/night splint/stretch/orthoses etc if appropriate.

    All that being said, I think the tibial torsion the least represented intoeing cause, or at least in the kids that I see, but the one that would be most appropriate for gait plates if you were that way inclined. I do however think they are a totally inappropriate modality of treatment and cosmetic fix for the other intoeing causes.
     
  23. How much force is enough force?
     
  24. Bug

    Bug Well-Known Member

    Exactly!!! I do a bit of serial casting, as in, I generally have one baby/toddler in plaster at any one time. I am so aware that the pressure I can exert with my hands over a 6 week period can change the shape of a foot. Radiologically proven and within the literature it shows permanent and long term change.

    How much force then does an orthotic place on a foot, under weight, that a child wears for years, Surely we have to conceded it will have some permanent changing effect.
     
  25. aliciaj

    aliciaj Member

    Hi Guys,

    As a new member to the group I find this debate challanging and insightful. I personally have never issued a pair gait plates, though I have learnt the theory at university and I am aware of clinical relevance and result that are achieved cosmetically.

    I struggle with the word "cosmetic" (I have to admit i'm not a parent), cosmetically yet what are we actually treating, correcting, altering, adjusting, forcfully changing, deforming or even just putting in a shoe to keep a mother content!


    In response Bug's comment I completely agree what a we actually treating, foot, tibia, femur or hips. Does this treatment actually physically correct any of these deformities?

    Are we infact correcting a deformity or completely going against or health professional grain by using adversion therapy by acknowledge we are inflicting pain on child. Any child will tell you it doesn't hurt as their parents have praised for their "fantastic walking"!! Are we forcing a foot to bend in a direction that against the biomechanical principals we blab on about. Alot of our biomechanical principals are based legends within this discussion yet gait plates affectively go against 1st ray function (windlass mechanism), mid tarsal support, and sub talar joint neutral. A gait plate forces a foots intrinic muscular component to bend only at one two and three metatarsal what is happening at toe off to the other digits and joints?


    What does a gait plate do to gross motor skill development? Can a child jump, hop run or even accelerate in a plate that doesn't bend???

    Okay so one question has led to 20 questions??????

    Alicia
     
  26. HerdySG

    HerdySG Welcome New Poster

    Hi there Kevin, bit late in jumping in on this conversation ;)...

    are you able to let me know which night splints you use/brands? I am based in Singapore and it isn't easy to order products. Do you ever use dennis browne bars for severe cases?

    We often use the spiral thigh braces from a company called "Spiral Skins". A physio out of Perth, Australia came up with them. These have worked great for us, but I'm searching for other options and was hoping you might have some? apart from derotation straps are there any others you know of?

    cheers
    matt
     
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