When should we biomechanically treat a child?

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Kevin & I have been having an interesting discussion on this. Some key points:

Kevin wrote:

what say you?

 

It's an interesting debate. Difficult to say really (otherwise you probably wouldn't be debating it!). How about prophylactic surgery? Potentially, podiatrists could use foot orthoses, serial casting or surgery of the foot and ankle to provide the child with a limb that most closely resembles the average non-pathological limb (whatever that is!).

Do you or don't you treat? And how far would you be prepared to go with your patient's best interests at heart?

Tough one.

 

The answer to this is easy. We should treat if:
1. The child is symptomatic
2. The child is at risk of developing problems

The practical application of this is more difficult. In the absence of evidence for (2) it becomes an ethical decision as to where the "line-in-the-sand" is on to intervene or not. All debates and arguments are really about where that "line-in-the-sand" is.

We already had the debate here:
Foot orthoses and asymptomatic pediatric flatfoot
Its also come up in many other threads

 

As clinicians, if we think we can influence permanent changes in structure for the better; we must also conceed that we can influence permanent changes for the worst.

Kevin is right, but the risk-reward is high early as well.


Unfortunately, the clinicians that try more and are less conservative (ie. do more than trying a 1mm piece of poron as an insole) are the ones that will get the big wins, but also the occasional losses.

Those that aim low, won't get the huge wins, but wont get any complaints either.


As musculo-skeletal clinicians that tamper with the levers of the body, we can make them better, but we can also make them worse.


As for treating kids, I think the way we would treat our own, is maybe the optimum way of looking at it. Symptomatic are the easiest to treat, because symptoms will determine treatment appropriateness. If I was to provide a pair for my asymptomatic kids, it would probably err on the side of comfort and favour mild forces epitomised by what orthotists issue by way of an EVA device.


Ron
Physiotherapist (Masters) & Podiatrist

 

I think that is as good as we get until we see more in the way of research with outcome measures. However I think as a profession we continue to under utilise the standardised functional assessment tools that are available to us. Our paediatric allied health colleagues assess and treat and measure how the function of the child changes with intervention and yet we don't?

A new graduate podiatrist can't access some tools that a new graduate physio and/or OT can access immediately on graduation but have similar subjects. We are a profession are not using everything out there that is available to us.

A symptom isn't always about pain, we need to get better at looking globally on what other symptoms a child may be presenting and rationalising our treatment based on those as well.

 

Ron:

This is an excellent posting and are some very wise words.:good:

The only thing I can add is that, as a clinician, the more one learns about the biomechanics, development and physiology of the human body and the more one makes continual careful observations of these pediatric cases over time, then the more confident the clinician will become in their knowledge that they are offering treatments with great reward/risk ratios for these patients and their parents. Treating children isn't for everyone, since many clinicians aren't trained properly in their special characteristics and/or don't understand their needs and/or simply don't like treating children. However for those that are properly trained and enjoy treating these young individuals, the rewards of these carefully thought-out conservative therapies far outweigh any risks to the child.

 

Cylie:

Excellent posting!:good:

Your point about "other symptoms" is very important and something that Dr. Valmassy hammered into us as podiatry students. You must not just ask the child (or their parent) if they are currently having pain, but also must ask if they are active in sports and if not, why not? Is it because their feet and/or lower extremities get pain when they attempt to participate in these sports so they don't participate because of pain? Do they wish they could run and play longer without getting pain? Do they complain of pain in their feet and lower extremities when they go shopping trips or go to amusement parks (i.e. Disneyland is a favorite here in California) when they are on their feet for prolonged periods? These are all questions the clinician should ge asking when seeing these children.

Normal children run and play throughout the day, much more than most adults (and clinicians) realize. When they can't run and play with their peers, then this affects them not only physically, but also psychologically. Therefore, any research study that doesn't include both the physical and mental aspects of our treatments of these symptomatic and "asymptomatic" children, will not be studying the complete nature of the positive effects that we can have on the lives of these children with appropriate conservative therapies.

 

I liked this statement just so damn much that I needed it to be here again. Working with kids is so much about the whole child, the family, the educational setting etc. It is about the world this child engages in. I wish I could remember who to quote that wrote about the role of the feet is not only a functional role in a toddler, but a social role. They get you around to talk and learn and engage in your environment. They are more than the things on the end of your legs to a child.

I hold myself as pretty conservative in the treatment states but, when then when I do, there is absolutely no hesitation and 1mm poron. Frankly though, working with kids can just be so much fun.

 

One small tip with kids.

If you are struggling with them in any part of the process (subjective questioning...clinical exam...treatment), give them some silicon and catalyst (I am not sure about the hazardous ingredients, but I do make sure they wash their hands thoroughly afterwards).

Better than any toy in the inventory.

 

Here is a thought ....

A while back I came across a report of an abstract at a clinical gait analysis conference ... BUT, the actual abstract was not in the book of abstracts .. :-(

The reported study was a kinematic analysis of 3-9 yr olds (if I recall correctly); what jumped out at me from the report was that first MPJ dorsiflexion started occuring about a mean age of 6.? (something). ... which sort of make sense as we assume that is about the mean age when the adult heel-toe gait pattern develops ... but what struck me at the time I read this was ... what happens when the first MPJ dorsiflexion starts developing during gait ---> WINDLASS ! ... this is a really significant time in foot functional development.

 

Agreed Craig!!

What are we doing before that though, how do we do it and what are we affecting/changing biomechanically?

 

Theoretically the interventions pre-windlass vs post-windlass could be different and also different if the windlass is not working when the 1st MPJ dorsiflexions starts during gait development...

 

Wonderful debate. Feel inadaquate talking with 2 leading researchers. Did dissertation on pediatric flat feet and the literature out there is confusing to say the least. Some points of note were, a) to do noting before 6 years of age, b) if the foot is just flat and unsymptomatic, leave it alone, c). do not confuse a functional flat foot with a pronating foot. d). the scale of a 'normal foot' is huge and varies from author to author. e). if the foot is symptomatic why would you leave it. and finally according to my findings, the best orthotic for children is a DSIS.

 

Thanks and welcome!!!

Just wondering why a DSIS? If you have a look at what Craig wrote about the windlass, the DSIS would interfere with this wouldn't it? Why not just the triplanar wedge which is actually just the controlling point of the DSIS? I guess my main issue with those is that little Australian kids have such wide feet there is no hope of getting a DSIS or UCBL into a shoe and then a little chubby foot. There is just no room at all and then that leads to a stack of different problems.

Don't you worry about those researchers, they are generally quite gentle and only a teeny bit scary.

 

Sorry guys... DSIS stands for?

 

Hi Craig, had to look it up myself
"The Dynamic Stabilizing Innersole System (DSIS), first described by Jay, Schoenhaus, et. al., in 1992, is a device designed to limit abnormal motion, allow normal motion and encourage the developmental unwinding of fetal positions retained in the foot such as forefoot varus.
This orthosis is characterized by a deep, 5-degree varus offset heel seat (an intrinsic rearfoot post sometimes referred to as a Kirby skive). It has extended medial and lateral flanges similar to the UCBL. It incorporates a longitudinal split in the plantar aspect of the shell. This is designed to allow independent function of the medial and lateral columns of the foot. Theoretically, it allows for independent plantarflexion of the medial column while the lateral column is stabilized against the ground.
The authors hypothesized this would decrease the likelihood that the forefoot would maintain a varus position while the rearfoot is controlled, as might be expected from a rigid device such as a UCBL. If the device maintains the varus position of the forefoot, there is a reduced likelihood that normal developmental unwinding of the forefoot deformity will occur. The independent medial arm of the DSIS will allow plantarflexion of the medial column while the lateral column is controlled, allowing the forefoot varus to reduce with development.
Jay and Schoenhaus, et. al., in their own study of 50 children with and without the DSIS, found a statistically significant correction of hyperpronation with the use of the device. This device is ideal for the young child with a mild to moderate pes planovalgus deformity. It works well in the toddler and pre-school population in which developmental flatfoot is a frequent diagnosis and unwinding of the foot and leg is still occurring"

A short but soooo important thread, all the best, mark c

 

Cheers Mark
I thought the answer would be a lot simpler than that...

 

Hi Cylie,

I really liked reading what you had to say about working with children. I was wondering if you could elaborate on some of the tools you are talking about that our allied health colleagues assess and treat with, that we are not using. I work in a Community Health setting with other allied health professionals and they do use some development scales and tools, but as far as I am aware, nothing that would generally be able to be used in podiatry as well (apart from general age-for-stage measurements to check overall development of gross and fine motor skills).

I am a fairly new graduate podiatrist, and I really enjoy working with children but I do find that biomechanically I am challenged when they present to our clinic, and I know I still have a whole lot to learn. I want to make sure that when I treat with orthotics or wedges I can be confident that it is going to be useful (as Kevin said in another post on this thread) and also that we are assessing what is going on globally with the child. For example, I recently had a three year old present who is intoeing on her right foot, and also has quite a severe sight impediment (amongst other health issues), which I am sure plays quite a significant role in her gait and stability.

Thanks very much,

Mary

 

Hi Mary,

Glad that prompted you think more. Looking at your example, when you think of sight being one of the major influences on a child's function and how they see to get around, is it any wonder that a visual impairment can influence gait. An OT colleague often talked about how biomechanics and sensory impairment overlap. A child with a disbility that has a stomping/foot slap gait, is it due to poor biomechanics or is the way they need to walk to remind themselves where the floor is.

As far as standardised assessment, you might want to chat to your OT and physio collegues as some of these will be difficult to get your head around as a newish grad but still very relevent to podiatry when you know what you are looking for. It simply as it isn't something you will have been exposed to in your training. Tools like: Bot-2, ASQ, Peds, Peabody, DeGangi-Berk Test of Sensory Integration, Carolina Curriculum. Some are developmental assessments, functional but all involve the whole body, not just the feet. As pod's while feet are out thing, they are connected to a body that needs to do stuff. While we shouldn't need to know how assess a should, we do look and see if the shoulders are level when walking, therefore we should know when a child should be able to do a star jump and when then can't.

The trick is understanding what are you using them for, do you have the right training and do you know what to do with the scores. It is one thing to have great tools, another to know what to do with them.

Talk to your colleagues, upskill, as you have mentioned Community Health, I take it you are in Australia? If so, join a local Paed's special interest group or make contact with your association or one that does have one.

Good luck!
This is a

 

Amen!

Thanks Cylie, I think this little nugget is pure gold. I shall quote it to all students for ever after ;0) You have it in a nutshell.

I am loathe to treat an asymptomatic child - but symptoms of FUNCTION are as relevant as pain. Our standard (minimum) history includes, as Kevin Ithink mentioned earlier thing like: can they run around as much as they want to? can they do all the things that they want to do? Can the join in in PE etc? Tripping and falling?

Now, the outcomes of these your history and assesssment doesn't necessarily lead to orthoses (we are functional anatomists, not orthotic dispensing machines) and much much more than a one trick pony... it may be that through your assessment that you may suspect DCD (Developmental Coordination Disorder, the condition-formerly-known-as Dyspraxia), or referral to OT/PT may be the best course of action, or they may be hypermobile and just had a growth spurt. Many many children, respond so well, where they have weak or reduced acticvity in their post tib, simply by a program of strenghtening that. There are a number of good papers that cite the incidence of paediatric flat foot, we need to remember it is 'normal' for children. That means we don't have to address it.

Generally I will do a full assessment (inluding spine and upper limb), joint ranges, muscle strength. I can't tell you how many times, paeds problems are completely resoloved with some stretching and strengthening of the musculature that is determining the gait pattern. Once they have full range (usually 4-6weeks) they are nearly always better. Those that continue to have some minor symptoms, i know that it is not their muculatue and will prescribe orthoses then. It works. For all the best will in the world, where gait is determined by weak VMO and glut med they will not make those specific muscles stronger. Having said that, I would like to do some do a study into the influence that orthoses make on higher muscle firing vs stretching/strengthening first.

cheers,
sally