ORIGINAL ARTICLE
The Relationship Between Gait, Gross Motor Function, and Parental Perceived Outcome in Children With Clubfeet Lori A. Karol, MD, Kelly A. Jeans, MS, and Kimberly A. Kaipus, PT, MPT, PCS
Background: Assessment of children treated nonoperatively for idiopathic clubfoot, has primarily focused on the kinematic and kinetic results measured with gait analysis (GA). Excellent results in ankle motion and push-off power during gait have been reported at age 5; however, the assessment of gross motor function, has not been evaluated. The purpose of this study was to look at the relationship between gait measures, Peabody Developmental Motor Scales and parent-perception of their child’s outcome [measured with the Pediatric Outcomes Data Collection Instrument (PODCI)]. Methods: A total of 81 children with idiopathic clubfoot were seen for both GA and Peabody testing. Children who initially underwent the Ponseti technique (n = 29), the French Physical Therapy method (PT) (n = 23), and a group of children initially treated nonoperatively, but who required surgical intervention before GA at 5 years of age (n = 29) were enrolled. Pearson’s correlation coefficient was used to establish significant relationships between gait variables, Peabody, and PODCI scores. Results: Gait data showed that the Ponseti treated feet had significantly greater ankle power than feet treated surgically (P = 0.0075). The Peabody results showed that the PT feet had higher stationary (P = 0.0332) and overall gross motor quotient percent (GMQ%) scores (P = 0.0092) than the surgical feet. No differences were found in PODCI scores. Ankle power was weakly correlated to the GMQ% (r = 0.29; P = 0.0102); however, the GMQ% showed a strong correlation to the parent report of Global Functioning Scale on the PODCI (r = 0.48; P = 0.0005). Conclusions: Minimal gait disturbances do not interfere with function or parental assessment of abilities and satisfaction at 5-year follow-up in children with idiopathic clubfeet. Nonoperative correction of clubfeet should be the goal when possible, as the Peabody scores show better function as early as 5 years of age when surgery is not required. Level of Evidence: Level II—therapeutic.
From the Texas Scottish Rite Hospital for Children, Dallas, TX. Supported by the Texas Scottish Rite Hospital Research Fund. No outside funding was used. The authors declare no conflicts of interest. Reprints: Kelly A. Jeans, MS, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail: kelly.jeans@ tsrh.org. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 36, Number 2, March 2016
Key Words: clubfoot, gait analysis, Peabody motor scale, PODCI, outcomes (J Pediatr Orthop 2016;36:145–151)
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enewed interest in nonoperative treatment of children with idiopathic clubfoot deformity has led to increasing numbers of centers worldwide offering the Ponseti casting protocol. Early results have shown striking decreases in the number of children requiring surgical releases.1–11 Many reports have claimed that the Ponseti protocol is successful based solely on the lack of surgery in this patient population.2,12 Few centers in Europe and North America offer the French physical therapy method of correction for clubfoot, popularized by Bensahel and Dimeglio in France.13 Proponents of this program report reduced surgical rates as well, although the program has been modified during the last decade.14 Outcome studies of both the Ponseti15 and the French programs of clubfoot nonoperative correction focus on surgical rates, and report relapse rates after initial correction.6,16,17 Few studies have looked at functional tasks in children with clubfoot.18,19 Gait analysis (GA) has been used to quantify the function of children treated for clubfoot deformities.5,7,8,11,18,20–32 Kinematics have been reported in 227,29,32 and 5-year-old30 children from our center, and have documented that while more children who have not undergone surgical release have a higher likelihood of normal ankle motion during gait, joint kinematic abnormalities persist in some patients. Specifically, 2-year-old children treated with the French physical therapy method may have residual limitations of ankle dorsiflexion during stance phase. Patients treated with the Ponseti technique were more likely to have excessive dorsiflexion during stance, probably due to the Achilles tenotomy that is performed before the final cast in the majority of children. Both groups were found to have an internal foot progression angle in one-third of the patients. By age 5, GA shows fewer children in either equinus or excessive dorsiflexion, as those who had the greatest gait deviations were prone to undergo delayed surgical correction between ages 2 and 5 years. However, ankle power generation at terminal stance is reduced in all groups, but most markedly in patients following surgical release.30 www.pedorthopaedics.com |
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Although GA has carefully documented kinematic and kinetic differences in children with clubfeet, the clinician is left wondering what the functional implications of these gait deviations are, if any. Sala et al33 studied the effect of the Ponseti protocol on a child’s ability to achieve gross motor milestones (including rolling over, sitting, pullto-stand, cruising, and ambulating independently). Most milestones were achieved within 0.7 to 1.5 months, with the exception that independent ambulation was achieved with a 2.2-month delay. The number of studies assessing functional outcome after treatment for clubfoot, has been limited.18,19 Similarly, research on the parent’s perception has been limited to outcomes following the Ponseti protocol (the cast phase and brace phase) and identifying areas of difficulty during the treatment protocol.34 Parental perception of function has been previously reported in patients treated with the Ponseti technique compared with those treated surgically.7,35 The purpose of this study was to objectively measure gross motor function in children who were initially treated nonoperatively for idiopathic clubfoot with either the Ponseti casting protocol or with the French physical therapy method. Gross motor function was then compared with kinematic and kinetics obtained by instrumented GA. Finally, the differences in gross motor function between the 2 nonoperative groups and a third group of children who were initially treated nonoperatively, but then required surgery, was analyzed. Our aim was to document whether differences seen in GA correlate with diminished gross motor function or perceived limitations from the parents of children with clubfoot.
METHODS Children who received initial nonoperative treatment at our center for the diagnosis of idiopathic clubfoot were studied. Group 1 was defined as children treated solely by the Ponseti protocol (Ponseti), consisting of weekly long-leg casts, Achilles tenotomy as needed, and use of a foot abduction orthosis at the end of casting for 3 months full-time, and for 2 to 3 years at nights thereafter.15 Group 2 were children treated with the French physical therapy method (PT) of correction alone.13 This program entailed daily sessions of physical therapy to manipulate the foot, followed by taping the foot in the corrected position. Correction of the adductus and varus is usually obtained in the first few months of life; however, equinus has persisted in some feet. This has led to the inclusion of Achilles tenotomy in feet resistant to full correction.6,14 Foot abduction orthoses are not used in this method; however, a below the knee, ankle foot orthosis splint is used to hold the foot in position. Finally, group 3 included children that had either unsuccessful correction or relapse of clubfoot deformity and underwent surgical procedures. GA was conducted at 5 years of age. Kinematic and kinetic data were collected with a Vicon motion capture system (Vicon, Denver, CO) simultaneously with AMTI force plates (Advanced Mechanical Technology Inc., Watertown, MA) while participants walked at a self-se-
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lected speed. A standard Plug in Gait marker set was used and data were analyzed using Vicon Nexus. Kinematic and kinetic variables included: peak-ankle dorsiflexion in stance phase, peak-ankle plantarflexion, peak plantarflexion at toe-off, dynamic ankle range of motion, foot progression angle, and maximal ankle power generation at the transition from stance to swing phase. In bilateral patients, gait data from one involved limb was randomly selected for analysis. The Peabody Developmental Gross Motor Scale36 (Peabody) was administered to each child by a trained pediatric physical therapist either at the time of GA, or within a few months. The Peabody test is an examination of gross motor function that can be administered to children from infancy to 6 years of age. The test is divided into 3 domains. The stationary domain tests the ability of the body to sustain equilibrium and balance over the center of gravity. An example of a task within the stationary domain is the child’s ability to stand on their toes. The locomotion domain measures various forms of movement, such as running, jumping, and hopping. The object manipulation domain evaluates such skills as throwing, catching, and kicking a ball with each foot. The gross motor quotient is a composite score combining these 3 subsets and is reported as a percentile (GMQ%). It is also divided categorically based on the normal distribution: Poor, 0% to 10%; Below average, 11% to 25%; Average, 26% to 75%; and Above average, 76% to 100%. The Pediatric Outcomes Data Collection Instrument37 (PODCI) questionnaire was administered to the accompanying parent of the child. The parent perceptions of the following subscales were assessed: Transfer and Basic Mobility, Sports/Physical Functioning, Pain/Comfort, Happiness, and Global Function Scale (GFS). Three of these subscales (Transfer and Basic Mobility, Sports/ Physical Functioning, Pain/Comfort) and the Global Functioning Scale have been validated for use in children with orthopaedic conditions37 and are reported as a standardized mean. Statistical analysis of the data included ANOVA, with a post hoc Tukey test to establish differences between the groups. Pearson’s correlation coefficient was then run between gait variables, Peabody scores, and PODCI scores. Alpha was set to 0.05.
RESULTS One hundred five patients with idiopathic clubfoot were enrolled into the study. The children were randomly recruited from a large prospective multiyear study of the treatment of clubfoot. Children were excluded (n = 24) for the following reasons: 1 had a subsequent diagnosis other than idiopathic clubfoot at follow-up, 13 had prior treatment at an outside facility, 5 had a combination of PT and Ponseti treatment but not surgery, and 5 children had bilateral clubfeet with 1 foot remaining nonoperative but the other requiring surgery. The remaining 81 children comprise the study group. There were 27 girls and 54 Copyright
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Function and Parent Perception Following CF Treatment
TABLE 1. Surgical Table Including Procedures No. Procedures Surgery #1 (n = 29 patients) Posterior release Posterior medial release Anterior tibialis tendon transfer with/without TAL Plantar release with/without TAL TAL (open or repeated) Surgery #2 (n = 7 patients) Anterior tibialis tendon transfer with/without TAL Tibial osteotomy Posterior release Plantar release Lateral column shortening Surgery #3 (n = 1 patient) Posterior medial release and anterior tibialis tendon transfer
11 7 5 4 4 4 2 2 1 1 1
TAL indicates Tendo Achilles lengthening.
boys. Twenty-nine children had been treated only by the Ponseti technique, 23 by the PT method, and 29 failed nonoperative treatment and underwent a surgery (Table 1). The surgical group was comprised of children who initially started the Ponseti program (n = 10), the PT program (n = 14), and a group of children that had a combination of the 2 forms of treatment (n = 5), before surgery. The average initial Dimeglio severity score14 was 13.2 ± 2.6 for the Ponseti group, 11.7 ± 2.7 for the PT group, and 14.1 ± 2.1 for the surgical feet. Patients with bilateral clubfoot were present in 41% of the Ponseti, 43% of the PT, and 48% of the surgical groups. For inclusion in the study, all children underwent GA and Peabody testing within 12 months (Peabody scoring is age normalized, accounting for maturation in the young child). The average age at GA was 5.1 ± 0.2 years in the Ponseti group, 5.2 ± 0.2 years in the PT group, and 5.1 ± 0.3 years in the surgical group (range, 4.2 to 6.0 y). The age at time of Peabody testing averaged 5.0 ± 0.2 years for the Ponseti group, 5.3 ± 0.3 years for the PT feet, and 5.1 ± 0.3 years for the surgical feet (range, 4.2 to 6.0 y). The PT group was significantly older
than both the Ponseti and Surgical groups at the time they completed the Peabody (P < 0.05). GA showed no significant differences in average kinematic data between the 3 groups. However, kinetic data [23 PT, 29 Ponseti, and 27 (of 29) Surgical participants] showed that patients treated with the Ponseti method had significantly greater ankle power generation (3.2 ± 0.8 W/kg) than patients who had undergone surgery (2.6 ± 0.7 W/kg; P = 0.0075), but the difference in ankle power between the 2 nonoperative groups did not reach statistical significance. Results from the Peabody test showed the average GMQ% was 46.9% for the Ponseti group, 55.4% for the PT group, and 40.6% for the surgical group. The PT group scored highest in all domains of the Peabody compared with the other groups, but the difference reached statistical significance only in the stationary assessment skills (P = 0.0332) and in the overall GMQ% (P = 0.0092) compared with the surgery group (Table 2). Between 72% and 87% of these children in the study scored in the Average range for the GMQ. In comparing the gross motor rankings across the 3 groups, only 1 patient scored in the Poor category, and he had undergone surgery. Of the surgical patients, 6 (21%) scored Below average, compared with 1 child in the PT cohort (4%) and 4 (14%) in the Ponseti group (Fig. 1). The Above average GMQ ranking was present in one (3%) of the surgical patients, one (3%) of the Ponseti patients, and 2 of (9%) of the PT patients. In combining nonsurgical modalities and comparing them to the children who had undergone surgery, only 10% of the 52 nonoperative children had GMQ’s below average (ie, Surgical. GMQ% indicates gross motor quotient percent; GFS, Global Function Scale; PODCI, Pediatric Outcomes Data Collection Instrument; PT, French physical therapy method. P < 0.05.
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FIGURE 1. Peabody Gross Motor Quotient Rankings between Groups. Diagonal, Ponseti casting technique; dotted, PT method; and solid, surgical feet. On the basis of the normal distribution: 0% to 10%, Poor; 11% to 25%, Below average; 26% to 75%, Average; 76% to 100%, Above average.
correlations were made between gait variables and Peabody scores. Increased peak plantarflexion, plantarflexion at toe-off, and decreased stance phase dorsiflexion correlated with higher scores on the Peabody stationary domain. Greater ankle power correlated with higher stationary, locomotion, and GMQ% scores on the Peabody. In analyzing the relationship between the gait data and the PODCI domains, we found moderate correlations. Decreased ankle dorsiflexion in stance phase (as is seen in the PT feet) correlated with better scores in transfers/ mobility, pain and comfort, and GFS. Increased peak plantarflexion (as is typical of both nonoperative groups) correlated with improved pain and comfort scores and the GFS. Finally the relationship between performance on the Peabody test and parent-perceived functional outcome was analyzed (Table 4). Patients with higher stationary skills were scored significantly higher in the sports/physical functioning, pain and comfort domains, and the GFS. Interestingly, patients who scored higher on the
locomotion section of the Peabody, which measures running and jumping, scored significantly higher on all domains of the PODCI, and highest in the overall PODCI score. Finally, the relationship between the GMQ% (ie, the overall score compared with normal children) on the Peabody strongly correlated with all domains of the PODCI, with P-values ranging from 0.0076 for the transfer domain to 0.0002 for the sports/physical functioning domain. The relationship between the overall GFS on the PODCI and the GMQ score on the Peabody was highly significant (r = 0.48; P = 0.0005).
DISCUSSION Over the last 10 years, several papers have reported on the outcome of children with clubfoot measured using instrumented GA.5,7,8,11,18,27–32 Our laboratory reported unsatisfactory gait results in patients who underwent posteromedial release at 10-year follow-up, finding diminished ankle motion, limitations in push-off power at
TABLE 3. Pearson’s Correlation Coefficient: Gait Variables to Peabody and PODCI Scores Gait Variables Peak Dorsiflexion r Peabody Stationary Locomotive GMQ% PODCI Transfer/basic mobility Pain/comfort GFS
Peak Plantarflexion
Plantarflexion at Toe-off r
P
Peak-ankle Power
P
r
P
r
P
0.22 0.09 0.11
0.0460 0.4453 0.3068
0.23 0.15 0.19
0.0407 0.1940 0.0853
0.22 0.0864 0.1127
0.0446 0.4430 0.3166
0.27 0.28 0.29
0.0143 0.0111 0.0102
0.32 0.34 0.33
0.0215 0.0140 0.0201
0.21 0.32 0.31
0.1379 0.0242 0.0292
0.0585 0.0542 0.0313
0.6833 0.7057 0.8292
0.1245 0.2139 0.2324
0.3942 0.1399 0.1120
GMQ% indicates gross motor quotient percent; PODCI, Pediatric Outcomes Data Collection Instrument. P < 0.05.
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TABLE 4. Pearson’s Correlation Coefficient: Peabody and PODCI Scores PODCI Transfer/Basic Mobility Variable Peabody Stationary Locomotive GMQ%
Sports/Physical Functioning
Pain/Comfort
Happiness
GFS
r
P
r
P
r
P
r
P
r
P
— 0.36 0.37
— 0.0102 0.0076
0.37 0.47 0.50
0.0083 0.0005 0.0002
0.30 0.35 0.40
0.0339 0.0119 0.0033
— 0.35 0.41
— 0.0122 0.0028
0.34 0.44 0.48
0.0173 0.0012 0.0005
GMQ% indicates gross motor quotient percent; PODCI, Pediatric Outcomes Data Collection Instrument. P < 0.05.
the ankle, and a 26% difference in isokinetic strength of the gastrocsoleus muscle.23 Yet the patients who were enrolled for this study were not being considered for further surgery, and were believed, although not objectively assessed, to be satisfied with their feet. Results such as this and other reports led to a change in the treatment of clubfeet at our center, first by the institution of the French PT program, and then 3 years later with the adoption of the Ponseti method. Gait results at age 5 years comparing nonoperative and surgically treated clubfeet, showed improved ankle power and motion in the nonoperative feet, but there were subtle abnormalities present in the kinematic graphs of the nonoperative groups as well.30 Young patients who had undergone the French PT method had slight limitation of ankle dorsiflexion in stance phase, leading to a change in protocol to include an Achilles tenotomy in the subset of therapy feet that have persistent equinus.6,29 At 2 years of age, El Hawary showed increased stance phase dorsiflexion during second rocker, in feet treated with the Ponseti program.29 It was postulated that this was likely due to the Achilles tenotomy that is typically performed in these feet. As has been documented in previous studies from our institution, the PT group had, on an average, 2 degrees less dorsiflexion in midstance phase compared with the other 2 groups, but this was not significant. Also, as has been previously published, the surgical group had the least plantarflexion at toe-off secondary to mild postoperative stiffness or weakness. Because of the small differences, however, and the small study groups, none of the kinematic differences, even though characteristic for clubfeet, were significantly different from each other or from age-matched normal values. Intoeing was greatest in the surgical group, with an average foot progression angle of 3.1 degrees internal, compared with the age-matched normal of 8.2 degrees external. Presentations of this data inevitably led to questions about the functional importance of the gait differences that were present in the children treated not only nonoperatively, but even those who had undergone surgery. Are small increases in ankle dorsiflexion or statistically significant decreases in ankle power generation clinically significant? We undertook this study to attempt to address this question. Copyright
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The Peabody test is a validated tool in wide use in physical therapy to assess how abnormal the gross motor function of a child is compared with their age-matched peers. The Peabody has been used in clinical investigations of prematurely born children38,39 and young patients with cerebral palsy40,41 but has not previously been used to our knowledge in children with clubfeet. It was selected due to its wide range of clinical applications and the particular skills that it assesses. It is logical that if disturbances in motion or strength of the foot and ankle exist, that such skills as toe-walking, standing on 1 leg, jumping, and running may be more challenging. In review of the results of this study, it is encouraging that the vast majority of patients with idiopathic clubfoot, regardless of which treatment group they were in, have average gross motor function at the age of 5 years. Furthermore, it seems that the results of the Peabody support the continued benefit of nonoperative treatment in children with clubfoot. Although most surgical feet had “average” GMQ%, those children with below average scores were most likely to be in the surgical group. The PODCI analysis yielded very interesting results. Although no significant differences were found between groups across the domains, parents of children treated with the PT technique scored their children highest in all domains. The PT technique is a very laborious and timeconsuming process, requiring significant parent time and emotional investment in the method. Frequent visits to the therapist in the newborn period, parental taping and exercises, and close follow-up with the therapist are required for successful outcomes. The children in our PT group had successful outcomes in that they avoided surgery, and perhaps the high scores from their parents validates the investment they had made to the performance and adherence to the method. Parents of children treated by the Ponseti method scored their children slightly lower on happiness compared with the other groups. It can be proposed that the prolonged use of the nighttime foot abduction orthosis34 may have led to less overall satisfaction with the technique. After the Ponseti technique, the children function as well or better than the children who underwent surgical management, and their gait results as evidenced by lack of intoeing and improved ankle power indicate successful nonoperative results. www.pedorthopaedics.com |
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The struggles of using the nighttime orthosis are readily expressed in our clinic visits, and this may have an impact on the parent assessment of outcome, albeit only slightly. Overall, the results of this study are quite reassuring. Minimal gait disturbances do not interfere with function or parental assessment of abilities and satisfaction at 5-year follow-up in children with idiopathic clubfeet. Nonoperative correction of clubfeet should be the goal when possible, as the Peabody scores show better function as early as 5 years of age when surgery is not required. Longer follow-up is needed, as it is not typical for the kindergarten age child with a treated clubfoot to note pain or functional difficulties. A comprehensive study of the results of nonoperatively treated 10-year-old patients with clubfeet, comprised of GA, pedobarography, isokinetic strength measurement, gross motor function, and patient-based outcomes is underway at our center. We conclude that mild kinematic and kinetic gait disturbances may persist in some children treated nonoperatively for idiopathic clubfeet, but functional difficulties rarely exist or are perceived at the age of 5 years. ACKNOWLEDGMENTS The authors thank Stacy Pritchard, PT for initiating the use of the Peabody Motor scale in our clubfoot population. The authors also thank both the pediatric Physical Therapists and the staff in the Movement Science Lab, who helped with data collection.
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11. Smith PA, Kuo KN, Graf AN, et al. Long-term results of comprehensive clubfoot release versus the Ponseti method: which is better? Clin Orthop Relat Res. 2014;472:1281–1290. 12. Zhao D, Li H, Zhao L, et al. Results of clubfoot management using the Ponseti method: do the details matter? A systematic review. Clin Orthop Relat Res. 2014;472:1329–1336. 13. Masse P. Le traitement du pied bot par la methode “functionnelle”, in Cahier d’enseignement de la SOFCOT. Paris, France: Expansion Scientific; 1977:51–56. 14. Dimeglio A, Canavese F. The French functional physical therapy method for the treatment of congenital clubfoot. J Pediatr Orthop B. 2012;21:28–39. 15. Ponseti IV. The Ponseti technique for correction of congenital clubfoot. J Bone Joint Surg. 2002;84-A:1889–1890. 16. Halanski MA, Davison JE, Huang JC, et al. Ponseti method compared with surgical treatment of clubfoot: a prospective comparison. J Bone Joint Surg Am. 2010;92:270–278. 17. Chotel F, Parot R, Seringe R, et al. Comparative study: Ponseti method versus French physiotherapy for initial treatment of idiopathic clubfoot deformity. J Pediatr Orthop. 2011;31: 320–325. 18. Banskota B, Banskota AK, Regmi R, et al. The Ponseti method in the treatment of children with idiopathic clubfoot presenting between five and ten years of age. Bone Joint J. 2013;95-B: 1721–1725. 19. Kenmoku T, Kamegaya M, Saisu T, et al. Athletic ability of schoolage children after satisfactory treatment of congenital clubfoot. J Pediatr Orthop. 2013;33:321–325. 20. Otis JC, Bohne WH. Gait analysis in surgically treated clubfoot. J Pediatr Orthop. 1986;6:162–164. 21. Aronson J, Puskarich CL. Deformity and disability from treated clubfoot. J Pediatr Orthop. 1990;10:109–119. 22. Yamamoto H, Muneta T, Furuya K. Cause of toe-in gait after posteromedial release for congenital clubfoot. J Pediatr Orthop. 1994;14:369–371. 23. Karol LA, Concha MC, Johnston CE II. Gait analysis and muscle strength in children with surgically treated clubfeet. J Pediatr Orthop. 1997;17:790–795. 24. Alkjaer T, Pedersen EN, Simonsen EB. Evaluation of the walking pattern in clubfoot patients who received early intensive treatment. J Pediatr Orthop. 2000;20:642–647. 25. Davies TC, Kiefer G, Zernicke RF. Kinematics and kinetics of the hip, knee, and ankle of children with clubfoot after posteromedial release. J Pediatr Orthop. 2001;21:366–371. 26. Beyaert C, Haumont T, Paysant J, et al. The effect of inturning of the foot on knee kinematics and kinetics in children with treated idiopathic clubfoot. Clin Biomech (Bristol, Avon). 2003;18: 670–676. 27. Karol LA, O’Brien SE, Wilson H, et al. Gait analysis in children with severe clubfeet: early results of physiotherapy versus surgical release. J Pediatr Orthop. 2005;25:236–240. 28. Muratli HH, Dag˘li C, Yavuzer G, et al. Gait characteristics of patients with bilateral club feet following posteromedial release procedure. J Pediatr Orthop B. 2005;14:206–211. 29. El-Hawary R, Karol LA, Jeans KA, et al. Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique. J Bone Joint Surg Am. 2008;90:1508–1516. 30. Karol LA, Jeans K, ElHawary R. Gait analysis after initial nonoperative treatment for clubfeet: intermediate term follow-up at age 5. Clin Orthop Relat Res. 2009;467:1206–1213. 31. Aks¸ahin E, Yu¨ksel HY, Yavuzer G, et al. Quantitative gait characteristics of children who had successful unilateral clubfoot operation. Acta Orthop Traumatol Turc. 2010;44:378–384. 32. Gottschalk HP, Karol LA, Jeans KA. Gait analysis of children treated for moderate clubfoot with physical therapy versus the Ponseti cast technique. J Pediatr Orthop. 2010;30:235–239. 33. Sala DA, Chu A, Lehman WB, et al. Achievement of gross motor milestones in children with idiopathic clubfoot treated with the Ponseti method. J Pediatr Orthop. 2013;33:55–58.
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34. Nogueira MP, Farcetta M, Fox MH, et al. Treatment of congenital clubfoot with the Ponseti method: the parents’ perspective. J Pediatr Orthop B. 2013;22:583–588. 35. Zwick EB, Kraus T, Maizen C, et al. Comparison of Ponseti versus surgical treatment for idiopathic clubfoot: a short-term preliminary report. Clin Orthop Relat Res. 2009;467:2668–2676. 36. Folio R, Fewell R. Peabody Developmental Motor Scales. 2nd ed. Austin, TX: Pro-Ed; 2000. 37. Daltroy LH, Liang MH, Fossel AH, et al. The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change. Pediatric Outcomes Instrument Development Group. Pediatric Orthopaedic Society of North America. J Pediatr Orthop. 1998;18:561–571.
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38. Wouldes TA, Lagasse LL, Huestis MA, et al. Prenatal methamphetamine exposure and neurodevelopmental outcomes in children from 1 to 3 years. Neurotoxicol Teratol. 2014;42:77–84. 39. Wang TN, Howe TH, Lin KC, et al. Hand function and its prognostic factors of very low birth weight preterm children up to a corrected age of 24 months. Res Dev Disabil. 2014;35: 322–329. 40. Boulton JE, Kirsch SE, Chipman M, et al. Reliability of the peabody developmental gross motor scale in children with cerebral palsy. Phys Occup Ther Pediatr. 1995;15:37–52. 41. Mattern-Baxter K, McNeil S, Mansoor JK. Effects of home-based locomotor treadmill training on gross motor function in young children with cerebral palsy: a quasi-randomized controlled trial. Arch Phys Med Rehabil. 2013;94:2061–2067.
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The Relationship Between Gait, Gross Motor Function, and Parental Perceived Outcome in Children With Clubfeet Lori A. Karol, MD, Kelly A. Jeans, MS, and Kimberly A. Kaipus, PT, MPT, PCS
Background: Assessment of children treated nonoperatively for idiopathic clubfoot, has primarily focused on the kinematic and kinetic results measured with gait analysis (GA). Excellent results in ankle motion and push-off power during gait have been reported at age 5; however, the assessment of gross motor function, has not been evaluated. The purpose of this study was to look at the relationship between gait measures, Peabody Developmental Motor Scales and parent-perception of their child’s outcome [measured with the Pediatric Outcomes Data Collection Instrument (PODCI)]. Methods: A total of 81 children with idiopathic clubfoot were seen for both GA and Peabody testing. Children who initially underwent the Ponseti technique (n = 29), the French Physical Therapy method (PT) (n = 23), and a group of children initially treated nonoperatively, but who required surgical intervention before GA at 5 years of age (n = 29) were enrolled. Pearson’s correlation coefficient was used to establish significant relationships between gait variables, Peabody, and PODCI scores. Results: Gait data showed that the Ponseti treated feet had significantly greater ankle power than feet treated surgically (P = 0.0075). The Peabody results showed that the PT feet had higher stationary (P = 0.0332) and overall gross motor quotient percent (GMQ%) scores (P = 0.0092) than the surgical feet. No differences were found in PODCI scores. Ankle power was weakly correlated to the GMQ% (r = 0.29; P = 0.0102); however, the GMQ% showed a strong correlation to the parent report of Global Functioning Scale on the PODCI (r = 0.48; P = 0.0005). Conclusions: Minimal gait disturbances do not interfere with function or parental assessment of abilities and satisfaction at 5-year follow-up in children with idiopathic clubfeet. Nonoperative correction of clubfeet should be the goal when possible, as the Peabody scores show better function as early as 5 years of age when surgery is not required. Level of Evidence: Level II—therapeutic.
From the Texas Scottish Rite Hospital for Children, Dallas, TX. Supported by the Texas Scottish Rite Hospital Research Fund. No outside funding was used. The authors declare no conflicts of interest. Reprints: Kelly A. Jeans, MS, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail: kelly.jeans@ tsrh.org. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 36, Number 2, March 2016
Key Words: clubfoot, gait analysis, Peabody motor scale, PODCI, outcomes (J Pediatr Orthop 2016;36:145–151)
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enewed interest in nonoperative treatment of children with idiopathic clubfoot deformity has led to increasing numbers of centers worldwide offering the Ponseti casting protocol. Early results have shown striking decreases in the number of children requiring surgical releases.1–11 Many reports have claimed that the Ponseti protocol is successful based solely on the lack of surgery in this patient population.2,12 Few centers in Europe and North America offer the French physical therapy method of correction for clubfoot, popularized by Bensahel and Dimeglio in France.13 Proponents of this program report reduced surgical rates as well, although the program has been modified during the last decade.14 Outcome studies of both the Ponseti15 and the French programs of clubfoot nonoperative correction focus on surgical rates, and report relapse rates after initial correction.6,16,17 Few studies have looked at functional tasks in children with clubfoot.18,19 Gait analysis (GA) has been used to quantify the function of children treated for clubfoot deformities.5,7,8,11,18,20–32 Kinematics have been reported in 227,29,32 and 5-year-old30 children from our center, and have documented that while more children who have not undergone surgical release have a higher likelihood of normal ankle motion during gait, joint kinematic abnormalities persist in some patients. Specifically, 2-year-old children treated with the French physical therapy method may have residual limitations of ankle dorsiflexion during stance phase. Patients treated with the Ponseti technique were more likely to have excessive dorsiflexion during stance, probably due to the Achilles tenotomy that is performed before the final cast in the majority of children. Both groups were found to have an internal foot progression angle in one-third of the patients. By age 5, GA shows fewer children in either equinus or excessive dorsiflexion, as those who had the greatest gait deviations were prone to undergo delayed surgical correction between ages 2 and 5 years. However, ankle power generation at terminal stance is reduced in all groups, but most markedly in patients following surgical release.30 www.pedorthopaedics.com |
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Although GA has carefully documented kinematic and kinetic differences in children with clubfeet, the clinician is left wondering what the functional implications of these gait deviations are, if any. Sala et al33 studied the effect of the Ponseti protocol on a child’s ability to achieve gross motor milestones (including rolling over, sitting, pullto-stand, cruising, and ambulating independently). Most milestones were achieved within 0.7 to 1.5 months, with the exception that independent ambulation was achieved with a 2.2-month delay. The number of studies assessing functional outcome after treatment for clubfoot, has been limited.18,19 Similarly, research on the parent’s perception has been limited to outcomes following the Ponseti protocol (the cast phase and brace phase) and identifying areas of difficulty during the treatment protocol.34 Parental perception of function has been previously reported in patients treated with the Ponseti technique compared with those treated surgically.7,35 The purpose of this study was to objectively measure gross motor function in children who were initially treated nonoperatively for idiopathic clubfoot with either the Ponseti casting protocol or with the French physical therapy method. Gross motor function was then compared with kinematic and kinetics obtained by instrumented GA. Finally, the differences in gross motor function between the 2 nonoperative groups and a third group of children who were initially treated nonoperatively, but then required surgery, was analyzed. Our aim was to document whether differences seen in GA correlate with diminished gross motor function or perceived limitations from the parents of children with clubfoot.
METHODS Children who received initial nonoperative treatment at our center for the diagnosis of idiopathic clubfoot were studied. Group 1 was defined as children treated solely by the Ponseti protocol (Ponseti), consisting of weekly long-leg casts, Achilles tenotomy as needed, and use of a foot abduction orthosis at the end of casting for 3 months full-time, and for 2 to 3 years at nights thereafter.15 Group 2 were children treated with the French physical therapy method (PT) of correction alone.13 This program entailed daily sessions of physical therapy to manipulate the foot, followed by taping the foot in the corrected position. Correction of the adductus and varus is usually obtained in the first few months of life; however, equinus has persisted in some feet. This has led to the inclusion of Achilles tenotomy in feet resistant to full correction.6,14 Foot abduction orthoses are not used in this method; however, a below the knee, ankle foot orthosis splint is used to hold the foot in position. Finally, group 3 included children that had either unsuccessful correction or relapse of clubfoot deformity and underwent surgical procedures. GA was conducted at 5 years of age. Kinematic and kinetic data were collected with a Vicon motion capture system (Vicon, Denver, CO) simultaneously with AMTI force plates (Advanced Mechanical Technology Inc., Watertown, MA) while participants walked at a self-se-
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lected speed. A standard Plug in Gait marker set was used and data were analyzed using Vicon Nexus. Kinematic and kinetic variables included: peak-ankle dorsiflexion in stance phase, peak-ankle plantarflexion, peak plantarflexion at toe-off, dynamic ankle range of motion, foot progression angle, and maximal ankle power generation at the transition from stance to swing phase. In bilateral patients, gait data from one involved limb was randomly selected for analysis. The Peabody Developmental Gross Motor Scale36 (Peabody) was administered to each child by a trained pediatric physical therapist either at the time of GA, or within a few months. The Peabody test is an examination of gross motor function that can be administered to children from infancy to 6 years of age. The test is divided into 3 domains. The stationary domain tests the ability of the body to sustain equilibrium and balance over the center of gravity. An example of a task within the stationary domain is the child’s ability to stand on their toes. The locomotion domain measures various forms of movement, such as running, jumping, and hopping. The object manipulation domain evaluates such skills as throwing, catching, and kicking a ball with each foot. The gross motor quotient is a composite score combining these 3 subsets and is reported as a percentile (GMQ%). It is also divided categorically based on the normal distribution: Poor, 0% to 10%; Below average, 11% to 25%; Average, 26% to 75%; and Above average, 76% to 100%. The Pediatric Outcomes Data Collection Instrument37 (PODCI) questionnaire was administered to the accompanying parent of the child. The parent perceptions of the following subscales were assessed: Transfer and Basic Mobility, Sports/Physical Functioning, Pain/Comfort, Happiness, and Global Function Scale (GFS). Three of these subscales (Transfer and Basic Mobility, Sports/ Physical Functioning, Pain/Comfort) and the Global Functioning Scale have been validated for use in children with orthopaedic conditions37 and are reported as a standardized mean. Statistical analysis of the data included ANOVA, with a post hoc Tukey test to establish differences between the groups. Pearson’s correlation coefficient was then run between gait variables, Peabody scores, and PODCI scores. Alpha was set to 0.05.
RESULTS One hundred five patients with idiopathic clubfoot were enrolled into the study. The children were randomly recruited from a large prospective multiyear study of the treatment of clubfoot. Children were excluded (n = 24) for the following reasons: 1 had a subsequent diagnosis other than idiopathic clubfoot at follow-up, 13 had prior treatment at an outside facility, 5 had a combination of PT and Ponseti treatment but not surgery, and 5 children had bilateral clubfeet with 1 foot remaining nonoperative but the other requiring surgery. The remaining 81 children comprise the study group. There were 27 girls and 54 Copyright
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TABLE 1. Surgical Table Including Procedures No. Procedures Surgery #1 (n = 29 patients) Posterior release Posterior medial release Anterior tibialis tendon transfer with/without TAL Plantar release with/without TAL TAL (open or repeated) Surgery #2 (n = 7 patients) Anterior tibialis tendon transfer with/without TAL Tibial osteotomy Posterior release Plantar release Lateral column shortening Surgery #3 (n = 1 patient) Posterior medial release and anterior tibialis tendon transfer
11 7 5 4 4 4 2 2 1 1 1
TAL indicates Tendo Achilles lengthening.
boys. Twenty-nine children had been treated only by the Ponseti technique, 23 by the PT method, and 29 failed nonoperative treatment and underwent a surgery (Table 1). The surgical group was comprised of children who initially started the Ponseti program (n = 10), the PT program (n = 14), and a group of children that had a combination of the 2 forms of treatment (n = 5), before surgery. The average initial Dimeglio severity score14 was 13.2 ± 2.6 for the Ponseti group, 11.7 ± 2.7 for the PT group, and 14.1 ± 2.1 for the surgical feet. Patients with bilateral clubfoot were present in 41% of the Ponseti, 43% of the PT, and 48% of the surgical groups. For inclusion in the study, all children underwent GA and Peabody testing within 12 months (Peabody scoring is age normalized, accounting for maturation in the young child). The average age at GA was 5.1 ± 0.2 years in the Ponseti group, 5.2 ± 0.2 years in the PT group, and 5.1 ± 0.3 years in the surgical group (range, 4.2 to 6.0 y). The age at time of Peabody testing averaged 5.0 ± 0.2 years for the Ponseti group, 5.3 ± 0.3 years for the PT feet, and 5.1 ± 0.3 years for the surgical feet (range, 4.2 to 6.0 y). The PT group was significantly older
than both the Ponseti and Surgical groups at the time they completed the Peabody (P < 0.05). GA showed no significant differences in average kinematic data between the 3 groups. However, kinetic data [23 PT, 29 Ponseti, and 27 (of 29) Surgical participants] showed that patients treated with the Ponseti method had significantly greater ankle power generation (3.2 ± 0.8 W/kg) than patients who had undergone surgery (2.6 ± 0.7 W/kg; P = 0.0075), but the difference in ankle power between the 2 nonoperative groups did not reach statistical significance. Results from the Peabody test showed the average GMQ% was 46.9% for the Ponseti group, 55.4% for the PT group, and 40.6% for the surgical group. The PT group scored highest in all domains of the Peabody compared with the other groups, but the difference reached statistical significance only in the stationary assessment skills (P = 0.0332) and in the overall GMQ% (P = 0.0092) compared with the surgery group (Table 2). Between 72% and 87% of these children in the study scored in the Average range for the GMQ. In comparing the gross motor rankings across the 3 groups, only 1 patient scored in the Poor category, and he had undergone surgery. Of the surgical patients, 6 (21%) scored Below average, compared with 1 child in the PT cohort (4%) and 4 (14%) in the Ponseti group (Fig. 1). The Above average GMQ ranking was present in one (3%) of the surgical patients, one (3%) of the Ponseti patients, and 2 of (9%) of the PT patients. In combining nonsurgical modalities and comparing them to the children who had undergone surgery, only 10% of the 52 nonoperative children had GMQ’s below average (ie, Surgical. GMQ% indicates gross motor quotient percent; GFS, Global Function Scale; PODCI, Pediatric Outcomes Data Collection Instrument; PT, French physical therapy method. P < 0.05.
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FIGURE 1. Peabody Gross Motor Quotient Rankings between Groups. Diagonal, Ponseti casting technique; dotted, PT method; and solid, surgical feet. On the basis of the normal distribution: 0% to 10%, Poor; 11% to 25%, Below average; 26% to 75%, Average; 76% to 100%, Above average.
correlations were made between gait variables and Peabody scores. Increased peak plantarflexion, plantarflexion at toe-off, and decreased stance phase dorsiflexion correlated with higher scores on the Peabody stationary domain. Greater ankle power correlated with higher stationary, locomotion, and GMQ% scores on the Peabody. In analyzing the relationship between the gait data and the PODCI domains, we found moderate correlations. Decreased ankle dorsiflexion in stance phase (as is seen in the PT feet) correlated with better scores in transfers/ mobility, pain and comfort, and GFS. Increased peak plantarflexion (as is typical of both nonoperative groups) correlated with improved pain and comfort scores and the GFS. Finally the relationship between performance on the Peabody test and parent-perceived functional outcome was analyzed (Table 4). Patients with higher stationary skills were scored significantly higher in the sports/physical functioning, pain and comfort domains, and the GFS. Interestingly, patients who scored higher on the
locomotion section of the Peabody, which measures running and jumping, scored significantly higher on all domains of the PODCI, and highest in the overall PODCI score. Finally, the relationship between the GMQ% (ie, the overall score compared with normal children) on the Peabody strongly correlated with all domains of the PODCI, with P-values ranging from 0.0076 for the transfer domain to 0.0002 for the sports/physical functioning domain. The relationship between the overall GFS on the PODCI and the GMQ score on the Peabody was highly significant (r = 0.48; P = 0.0005).
DISCUSSION Over the last 10 years, several papers have reported on the outcome of children with clubfoot measured using instrumented GA.5,7,8,11,18,27–32 Our laboratory reported unsatisfactory gait results in patients who underwent posteromedial release at 10-year follow-up, finding diminished ankle motion, limitations in push-off power at
TABLE 3. Pearson’s Correlation Coefficient: Gait Variables to Peabody and PODCI Scores Gait Variables Peak Dorsiflexion r Peabody Stationary Locomotive GMQ% PODCI Transfer/basic mobility Pain/comfort GFS
Peak Plantarflexion
Plantarflexion at Toe-off r
P
Peak-ankle Power
P
r
P
r
P
0.22 0.09 0.11
0.0460 0.4453 0.3068
0.23 0.15 0.19
0.0407 0.1940 0.0853
0.22 0.0864 0.1127
0.0446 0.4430 0.3166
0.27 0.28 0.29
0.0143 0.0111 0.0102
0.32 0.34 0.33
0.0215 0.0140 0.0201
0.21 0.32 0.31
0.1379 0.0242 0.0292
0.0585 0.0542 0.0313
0.6833 0.7057 0.8292
0.1245 0.2139 0.2324
0.3942 0.1399 0.1120
GMQ% indicates gross motor quotient percent; PODCI, Pediatric Outcomes Data Collection Instrument. P < 0.05.
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TABLE 4. Pearson’s Correlation Coefficient: Peabody and PODCI Scores PODCI Transfer/Basic Mobility Variable Peabody Stationary Locomotive GMQ%
Sports/Physical Functioning
Pain/Comfort
Happiness
GFS
r
P
r
P
r
P
r
P
r
P
— 0.36 0.37
— 0.0102 0.0076
0.37 0.47 0.50
0.0083 0.0005 0.0002
0.30 0.35 0.40
0.0339 0.0119 0.0033
— 0.35 0.41
— 0.0122 0.0028
0.34 0.44 0.48
0.0173 0.0012 0.0005
GMQ% indicates gross motor quotient percent; PODCI, Pediatric Outcomes Data Collection Instrument. P < 0.05.
the ankle, and a 26% difference in isokinetic strength of the gastrocsoleus muscle.23 Yet the patients who were enrolled for this study were not being considered for further surgery, and were believed, although not objectively assessed, to be satisfied with their feet. Results such as this and other reports led to a change in the treatment of clubfeet at our center, first by the institution of the French PT program, and then 3 years later with the adoption of the Ponseti method. Gait results at age 5 years comparing nonoperative and surgically treated clubfeet, showed improved ankle power and motion in the nonoperative feet, but there were subtle abnormalities present in the kinematic graphs of the nonoperative groups as well.30 Young patients who had undergone the French PT method had slight limitation of ankle dorsiflexion in stance phase, leading to a change in protocol to include an Achilles tenotomy in the subset of therapy feet that have persistent equinus.6,29 At 2 years of age, El Hawary showed increased stance phase dorsiflexion during second rocker, in feet treated with the Ponseti program.29 It was postulated that this was likely due to the Achilles tenotomy that is typically performed in these feet. As has been documented in previous studies from our institution, the PT group had, on an average, 2 degrees less dorsiflexion in midstance phase compared with the other 2 groups, but this was not significant. Also, as has been previously published, the surgical group had the least plantarflexion at toe-off secondary to mild postoperative stiffness or weakness. Because of the small differences, however, and the small study groups, none of the kinematic differences, even though characteristic for clubfeet, were significantly different from each other or from age-matched normal values. Intoeing was greatest in the surgical group, with an average foot progression angle of 3.1 degrees internal, compared with the age-matched normal of 8.2 degrees external. Presentations of this data inevitably led to questions about the functional importance of the gait differences that were present in the children treated not only nonoperatively, but even those who had undergone surgery. Are small increases in ankle dorsiflexion or statistically significant decreases in ankle power generation clinically significant? We undertook this study to attempt to address this question. Copyright
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The Peabody test is a validated tool in wide use in physical therapy to assess how abnormal the gross motor function of a child is compared with their age-matched peers. The Peabody has been used in clinical investigations of prematurely born children38,39 and young patients with cerebral palsy40,41 but has not previously been used to our knowledge in children with clubfeet. It was selected due to its wide range of clinical applications and the particular skills that it assesses. It is logical that if disturbances in motion or strength of the foot and ankle exist, that such skills as toe-walking, standing on 1 leg, jumping, and running may be more challenging. In review of the results of this study, it is encouraging that the vast majority of patients with idiopathic clubfoot, regardless of which treatment group they were in, have average gross motor function at the age of 5 years. Furthermore, it seems that the results of the Peabody support the continued benefit of nonoperative treatment in children with clubfoot. Although most surgical feet had “average” GMQ%, those children with below average scores were most likely to be in the surgical group. The PODCI analysis yielded very interesting results. Although no significant differences were found between groups across the domains, parents of children treated with the PT technique scored their children highest in all domains. The PT technique is a very laborious and timeconsuming process, requiring significant parent time and emotional investment in the method. Frequent visits to the therapist in the newborn period, parental taping and exercises, and close follow-up with the therapist are required for successful outcomes. The children in our PT group had successful outcomes in that they avoided surgery, and perhaps the high scores from their parents validates the investment they had made to the performance and adherence to the method. Parents of children treated by the Ponseti method scored their children slightly lower on happiness compared with the other groups. It can be proposed that the prolonged use of the nighttime foot abduction orthosis34 may have led to less overall satisfaction with the technique. After the Ponseti technique, the children function as well or better than the children who underwent surgical management, and their gait results as evidenced by lack of intoeing and improved ankle power indicate successful nonoperative results. www.pedorthopaedics.com |
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The struggles of using the nighttime orthosis are readily expressed in our clinic visits, and this may have an impact on the parent assessment of outcome, albeit only slightly. Overall, the results of this study are quite reassuring. Minimal gait disturbances do not interfere with function or parental assessment of abilities and satisfaction at 5-year follow-up in children with idiopathic clubfeet. Nonoperative correction of clubfeet should be the goal when possible, as the Peabody scores show better function as early as 5 years of age when surgery is not required. Longer follow-up is needed, as it is not typical for the kindergarten age child with a treated clubfoot to note pain or functional difficulties. A comprehensive study of the results of nonoperatively treated 10-year-old patients with clubfeet, comprised of GA, pedobarography, isokinetic strength measurement, gross motor function, and patient-based outcomes is underway at our center. We conclude that mild kinematic and kinetic gait disturbances may persist in some children treated nonoperatively for idiopathic clubfeet, but functional difficulties rarely exist or are perceived at the age of 5 years. ACKNOWLEDGMENTS The authors thank Stacy Pritchard, PT for initiating the use of the Peabody Motor scale in our clubfoot population. The authors also thank both the pediatric Physical Therapists and the staff in the Movement Science Lab, who helped with data collection.
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11. Smith PA, Kuo KN, Graf AN, et al. Long-term results of comprehensive clubfoot release versus the Ponseti method: which is better? Clin Orthop Relat Res. 2014;472:1281–1290. 12. Zhao D, Li H, Zhao L, et al. Results of clubfoot management using the Ponseti method: do the details matter? A systematic review. Clin Orthop Relat Res. 2014;472:1329–1336. 13. Masse P. Le traitement du pied bot par la methode “functionnelle”, in Cahier d’enseignement de la SOFCOT. Paris, France: Expansion Scientific; 1977:51–56. 14. Dimeglio A, Canavese F. The French functional physical therapy method for the treatment of congenital clubfoot. J Pediatr Orthop B. 2012;21:28–39. 15. Ponseti IV. The Ponseti technique for correction of congenital clubfoot. J Bone Joint Surg. 2002;84-A:1889–1890. 16. Halanski MA, Davison JE, Huang JC, et al. Ponseti method compared with surgical treatment of clubfoot: a prospective comparison. J Bone Joint Surg Am. 2010;92:270–278. 17. Chotel F, Parot R, Seringe R, et al. Comparative study: Ponseti method versus French physiotherapy for initial treatment of idiopathic clubfoot deformity. J Pediatr Orthop. 2011;31: 320–325. 18. Banskota B, Banskota AK, Regmi R, et al. The Ponseti method in the treatment of children with idiopathic clubfoot presenting between five and ten years of age. Bone Joint J. 2013;95-B: 1721–1725. 19. Kenmoku T, Kamegaya M, Saisu T, et al. Athletic ability of schoolage children after satisfactory treatment of congenital clubfoot. J Pediatr Orthop. 2013;33:321–325. 20. Otis JC, Bohne WH. Gait analysis in surgically treated clubfoot. J Pediatr Orthop. 1986;6:162–164. 21. Aronson J, Puskarich CL. Deformity and disability from treated clubfoot. J Pediatr Orthop. 1990;10:109–119. 22. Yamamoto H, Muneta T, Furuya K. Cause of toe-in gait after posteromedial release for congenital clubfoot. J Pediatr Orthop. 1994;14:369–371. 23. Karol LA, Concha MC, Johnston CE II. Gait analysis and muscle strength in children with surgically treated clubfeet. J Pediatr Orthop. 1997;17:790–795. 24. Alkjaer T, Pedersen EN, Simonsen EB. Evaluation of the walking pattern in clubfoot patients who received early intensive treatment. J Pediatr Orthop. 2000;20:642–647. 25. Davies TC, Kiefer G, Zernicke RF. Kinematics and kinetics of the hip, knee, and ankle of children with clubfoot after posteromedial release. J Pediatr Orthop. 2001;21:366–371. 26. Beyaert C, Haumont T, Paysant J, et al. The effect of inturning of the foot on knee kinematics and kinetics in children with treated idiopathic clubfoot. Clin Biomech (Bristol, Avon). 2003;18: 670–676. 27. Karol LA, O’Brien SE, Wilson H, et al. Gait analysis in children with severe clubfeet: early results of physiotherapy versus surgical release. J Pediatr Orthop. 2005;25:236–240. 28. Muratli HH, Dag˘li C, Yavuzer G, et al. Gait characteristics of patients with bilateral club feet following posteromedial release procedure. J Pediatr Orthop B. 2005;14:206–211. 29. El-Hawary R, Karol LA, Jeans KA, et al. Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique. J Bone Joint Surg Am. 2008;90:1508–1516. 30. Karol LA, Jeans K, ElHawary R. Gait analysis after initial nonoperative treatment for clubfeet: intermediate term follow-up at age 5. Clin Orthop Relat Res. 2009;467:1206–1213. 31. Aks¸ahin E, Yu¨ksel HY, Yavuzer G, et al. Quantitative gait characteristics of children who had successful unilateral clubfoot operation. Acta Orthop Traumatol Turc. 2010;44:378–384. 32. Gottschalk HP, Karol LA, Jeans KA. Gait analysis of children treated for moderate clubfoot with physical therapy versus the Ponseti cast technique. J Pediatr Orthop. 2010;30:235–239. 33. Sala DA, Chu A, Lehman WB, et al. Achievement of gross motor milestones in children with idiopathic clubfoot treated with the Ponseti method. J Pediatr Orthop. 2013;33:55–58.
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34. Nogueira MP, Farcetta M, Fox MH, et al. Treatment of congenital clubfoot with the Ponseti method: the parents’ perspective. J Pediatr Orthop B. 2013;22:583–588. 35. Zwick EB, Kraus T, Maizen C, et al. Comparison of Ponseti versus surgical treatment for idiopathic clubfoot: a short-term preliminary report. Clin Orthop Relat Res. 2009;467:2668–2676. 36. Folio R, Fewell R. Peabody Developmental Motor Scales. 2nd ed. Austin, TX: Pro-Ed; 2000. 37. Daltroy LH, Liang MH, Fossel AH, et al. The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change. Pediatric Outcomes Instrument Development Group. Pediatric Orthopaedic Society of North America. J Pediatr Orthop. 1998;18:561–571.
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38. Wouldes TA, Lagasse LL, Huestis MA, et al. Prenatal methamphetamine exposure and neurodevelopmental outcomes in children from 1 to 3 years. Neurotoxicol Teratol. 2014;42:77–84. 39. Wang TN, Howe TH, Lin KC, et al. Hand function and its prognostic factors of very low birth weight preterm children up to a corrected age of 24 months. Res Dev Disabil. 2014;35: 322–329. 40. Boulton JE, Kirsch SE, Chipman M, et al. Reliability of the peabody developmental gross motor scale in children with cerebral palsy. Phys Occup Ther Pediatr. 1995;15:37–52. 41. Mattern-Baxter K, McNeil S, Mansoor JK. Effects of home-based locomotor treadmill training on gross motor function in young children with cerebral palsy: a quasi-randomized controlled trial. Arch Phys Med Rehabil. 2013;94:2061–2067.
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