Motor ability in children treated for idiopathic clubfoot. A controlled pilot study

<p>Abstract</p> <p>Background</p> <p>To study motor ability at seven years of age in children treated for idiopathic clubfoot and its relation to clubfoot laterality, foot status and the amount of surgery performed.</p> <p>Methods</p> <p>Twenty children (mean age 7.5 years, SD 3.2 months) from a consecutive birth cohort from our hospital catchments area (300.000 inhabitants from southern Sweden) were assessed with the Movement Assessment Battery for Children (MABC) and the Clubfoot Assessment Protocol (CAP).</p> <p>Results</p> <p>Compared to typically developing children an increased prevalence of motor impairment was found regarding both the total score for MABC (p < 0.05) and the subtest ABC-Ball skills (p < 0.05). No relationship was found between the child's actual foot status, laterality or the extent of foot surgery with the motor ability as measured with MABC. Only the CAP item "one-leg stand" correlated significantly with the MABC (rs = -0.53, p = 0.02).</p> <p>Conclusions</p> <p>Children with idiopathic clubfoot appear to have an increased risk of motor activity limitations and it is possible that other factors, independent of the clinical status, might be involved. The ability to keep balance on one leg may be a sufficient tool for determining which children in the orthopedic setting should be more thoroughly evaluated regarding their neuromotor functioning.</p

Validity and responsiveness of the Clubfoot Assessment Protocol (CAP). A methodological study

BACKGROUND: The Clubfoot Assessment Protocol (CAP) is a multi dimensional instrument designed for longitudinal follow up of the clubfoot deformity during growth. Item reliability has shown to be sufficient. In this article the CAP's validity and responsiveness is studied using the Dimeglio classification scoring as a gold standard. METHODS: Thirty-two children with 45 congenital clubfeet were assessed prospectively and consecutively at ages of new-born, one, two, four months and two years of age. For convergent/divergent construct validity the Spearman's correlation coefficients were calculated. Discriminate validity was evaluated by studying the scores in bilateral clubfeet. The floor-ceiling effects at baseline (untreated clubfeet) and at two years of age (treated clubfeet) were evaluated. Responsiveness was evaluated by using effect sizes (ES) and by calculating if significant changes (Wilcoxons signed test) had occurred between the different measurement occasions. RESULTS: High to moderate significant correlation were found between CAP mobility I and morphology and the Dimeglio scores (r(s )= 0.77 and 0.44 respectively). Low correlation was found between CAP muscle function, mobility II and motion quality and the Dimeglio scoring system (r(s )= 0.20, 0.09 and 0.06 respectively). Of 13 children with bilateral clubfeet, 11 showed different CAP mobility I scores between right and left foot at baseline (untreated) compared with 5 with the Dimeglio score. At the other assessment occasions the CAP mobility I continued to show higher discrimination ability than the Dimeglio. No floor effects and low ceiling effects were found in the untreated clubfeet for both instruments. High ceiling effects were found in the CAP for the treated children and low for the Dimeglio. Responsiveness was good. ES from untreated to treated ranged from 0.80 to 4.35 for the CAP subgroups and was 4.68 for the Dimeglio. The first four treatment months, the CAP mobility I had generally higher ES compared with the Dimeglio. CONCLUSION: The Clubfoot Assessment Protocol shows in this study good validity and responsiveness. The CAP is more responsive when severity ranges between mild – moderate to severe, while the Dimeglio focuses more on the extremes. The ability to discriminate between different mobility status of the right and left foot in bilaterally affected children in this population was higher compared with the Dimeglio score implicating a better sensitivity for the CAP

The clubfoot assessment protocol (CAP); description and reliability of a structured multi-level instrument for follow-up

BACKGROUND: In most clubfoot studies, the outcome instruments used are designed to evaluate classification or long-term cross-sectional results. Variables deal mainly with factors on body function/structure level. Wide scorings intervals and total sum scores increase the risk that important changes and information are not detected. Studies of the reliability, validity and responsiveness of these instruments are sparse. The lack of an instrument for longitudinal follow-up led the investigators to develop the Clubfoot Assessment Protocol (CAP). The aim of this article is to introduce and describe the CAP and evaluate the items inter- and intra reliability in relation to patient age. METHODS: The CAP was created from 22 items divided between body function/structure (three subgroups) and activity (one subgroup) levels according to the International Classification of Function, Disability and Health (ICF). The focus is on item and subgroup development. Two experienced examiners assessed 69 clubfeet in 48 children who had a median age of 2.1 years (range, 0 to 6.7 years). Both treated and untreated feet with different grades of severity were included. Three age groups were constructed for studying the influence of age on reliability. The intra- rater study included 32 feet in 20 children who had a median age of 2.5 years (range, 4 months to 6.8 years). The Unweighted Kappa statistics, percentage observer agreement, and amount of categories defined how reliability was to be interpreted. RESULTS: The inter-rater reliability was assessed as moderate to good for all but one item. Eighteen items had kappa values > 0.40. Three items varied from 0.35 to 0.38. The mean percentage observed agreement was 82% (range, 62 to 95%). Different age groups showed sufficient agreement. Intra- rater; all items had kappa values > 0.40 [range, 0.54 to 1.00] and a mean percentage agreement of 89.5%. Categories varied from 3 to 5. CONCLUSION: The CAP contains more detailed information than previous protocols. It is a multi-dimensional observer administered standardized measurement instrument with the focus on item and subgroup level. It can be used with sufficient reliability, independent of age, during the first seven years of childhood by examiners with good clinical experience. A few items showed low reliability, partly dependent on the child's age and /or varying professional backgrounds between the examiners. These items should be interpreted with caution, until further studies have confirmed the validity and sensitivity of the instrument

Follow-up of children with congenital clubfoot. Development of a new evaluation instrument.

Clubfoot is a congenital disorder, affecting about one of 1000 children. Treatment consists of initial correction of the deformity, followed by prolonged orthosis treatment to maintain the correction obtained. There are several different treatment options. Outcome studies, using reliable and valid instruments are rare. In this thesis an assessment instrument, Clubfoot Assessment Protocol (CAP) was developed for longitudinal follow up of children with clubfoot. The CAP provides information on the development of different functional domains (mobility, muscle function, morphology and motion quality) over time. The reliability, validity, responsiveness and clinical utility was analysed in a prospective sample of 73 consecutive children. The clinical utility was analysed by comparing Ponseti casting technique vs Copenhagen stretching method and by studying developmental motor problems in children born with clubfoot. The methodological studies showed that the CAP can be used with sufficient reliability and validity. For research purposes, experience of the CAP and data on actual inter observer differences should be described. The CAP showed a stronger ability to discriminate foot status than the Dimeglio Classification system (DCS). The CAP is more sensitive to change especially in the moderate to severe range. Thus, the CAP is an important contribution to clubfoot evaluation in clinical and in research settings. The casting technique according to Ponseti was superior in clubfoot correction regarding mobility and motion quality according to the CAP at age two years. Furthermore, less surgery was needed. The orthosis management showed maintenance or slight improvement of the clinical status along with good compliance. Developmental motor ability problems were found more often than expected among seven year old children treated for idiopathic clubfoot. This finding could not be explained by previous surgery or foot function. The ability to stand on one leg correlated strongest to motor problems and could serve as a screening test in clinical settings of clubfoot evaluation

Comparison of serial casting and stretching technique in children with congenital idiopathic clubfoot: Evaluation of a new assessment system.

Background and purpose The outcome of clubfoot treatment is the result of several factors such as severity, type of treatment, and measurement instruments. We compared two intervention groups with two assessment procedures. Patients and methods 16 children were treated consecutively with intensive stretching according to the Copenhagen method and 16 children consecutively with casting according to the Ponseti technique, during their first 2 months of age. The need for surgery was then assessed. At 4 months of age, all children used a dynamic Knee Ankle Foot Orthosis. The Clubfoot Assessment Protocol (CAP) and the Dimeglio Classification System (DCS) were used and compared during treatment and at 2 years of age. Results According to the CAP (but not the DCS) the casting technique was superior in clubfoot correction, apparent as better mobility and better quality of motion at 2 years of age. These children also required less surgery. The orthotics management functioned well in both groups, with high compliance and maintenance or slight improvement of the clinical status except for morphology. DCS score changed over time but not between the groups. Because of its multidimensional and narrower scoring interval construct, the CAP enabled us to elucidate and evaluate different clinical functions. Interpretation The casting technique according to Ponseti seems to be the better of the two for clubfoot correction, regarding mobility and quality of motion. The Clubfoot Assessment Protocol (but not the Dimeglio Classification System) was able to reveal differences between the Copenhagen and Ponseti treatment methods

Reliability and validity of motion analysis in children treated for congenital clubfoot according to the Clubfoot Assessment Protocol (CAP) using inexperienced assessors

Background. The Clubfoot Assessment Protocol (CAP) was developed for follow-up of children treated for clubfoot. The objective of this study was to analyze reliability and validity of the six items used in the domain CAPMotion Quality using inexperienced assessors. Findings. Four raters (two paediatric orthopaedic surgeons, two senior physiotherapists) used the CAP scores to analyze, on two different occasions, 11 videotapes containing standardized recordings of motion activity according to the domain CAPMotion Quality These results were compared to a criterion (two raters, well experienced CAP assessors) for validity and for checking for learning effect. Weighted kappa statistics, exact percentage observer agreement (Po), percentage observer agreement including one level difference (Po-1) and amount of scoring scales defined how reliability was to be interpreted. Inter- and intra rater differences were calculated using median and inter quartile ranges (IQR) on item level and mean and limits of agreement on domain level. Inter-rater reliability varied between fair and moderate (kappa) and had a mean agreement of 48/88% (Po/Po-1). Intra -rater reliability varied between moderate to good with a mean agreement of 63/96%. The intra- and inter-rater differences in the present study were generally small both on item (0.00) and domain level (-1.10). There was exact agreement of 51% and Po-1 of 91% of the six items with the criterion. No learning effect was found. Conclusion. The CAPMotion quality can be used by inexperienced assessors with sufficient reliability in daily clinical practice and showed acceptable accuracy compared to the criterion

Repeatability of sonographic measurements in clubfeet

Purpose: To assess the intra- and interobserver agreement of ultrasound assessment of clubfoot patho-anatomy in early childhood. Material and Methods: Seventeen clubfeet in 12 children were sequentially scanned by 2 examiners and repeat assessments were carried out independently. Three well-defined imaging planes were chosen to evaluate navicular displacement: the medial malleolus-navicular (MM-N) distance, soft tissue thickness, talar deformity and the calcaneocuboid (C-C) distance. Intra- and interobserver agreement was analysed using Cohen's kappa for the discrete variables and by Bland-Altman's graphic technique for measurements. Results: Kappa values for intra-observer agreement were 0.82 for navicular displacement, 0.93 for "talar head pointing laterally", and 0.70 for medial deviation of the talar neck. The corresponding interobserver kappa values were 0.70, 0.68, and 0.36. The mean difference between the two observers for the MM-N distance was 0.42+/-3.0 mm and for the soft tissue thickness 0.35+/-2.0 mm; the C-C distance showed a mean interobserver distance of 0.0+/-2.8 mm. Conclusion: The imaging planes used to study the talo-navicular and calcaneo-cuboid relationships are reproducible and relatively easy to learn. Intra- and interobserver assessments were acceptable for MM-N distance, soft tissue thickness, navicular displacement and "talar head pointing laterally", but questionable for the C-C distance and medial deviation of the talar neck

Epidemiology of clubfoot in Sweden from 2016 to 2019 : A national register study

BACKGROUND: This study aimed to estimate the birth prevalence of children born with isolated or non-isolated clubfoot in Sweden using a national clubfoot register. Secondarily we aimed to describe the clubfoot population with respect to sex, laterality, severity of deformity, comorbidity and geographic location.METHODS: A national register, the Swedish Pediatric Orthopedic Quality register, was used to extract data on newborn children with clubfoot. To calculate the birth prevalence of children with isolated or non-isolated clubfoot between 1st of January 2016 and 31st of December 2019, we used official reports of the total number of Swedish live births from the Swedish Board of Statistics. The Pirani score and predefined signs of atypical clubfoot were used to classify clubfoot severity at birth.RESULTS: In total 612 children with clubfoot were identified. Of these, 564 were children with isolated clubfoot, generating a birth prevalence of 1.24/1000 live births (95% confidence interval 1.15-1.35). About 8% were children with non-isolated clubfoot, increasing the birth prevalence to 1.35/1000 live births (95% confidence interval 1.25-1.46). Of the children with isolated clubfoot, 74% were boys and 47% had bilateral involvement. The children with non-isolated clubfoot had more severe foot deformities at birth and a greater proportion of clubfeet with atypical signs compared with children with isolated clubfoot.CONCLUSION: We have established the birth prevalence of children born with isolated or non-isolated clubfoot in Sweden based on data from a national register. Moreover, we have estimated the number of children born with atypical clubfeet in instances of both isolated and non-isolated clubfoot. These numbers may serve as a baseline for expected birth prevalence when planning clubfoot treatment and when evaluating time trends of children born with clubfoot

Development of foot length in children with congenital clubfoot up to 7 years of age : a prospective follow-up study

Background: Clubfeet are typically shorter than normal feet. This study aimed first to describe the development of foot length in a consecutive series of children with congenital clubfoot and second to relate foot length to development of relapse and motion quality. Methods: Foot length was measured every 6 months in 72 consecutive children with congenital clubfoot (29 bilateral) aged from 2 to 7 years. The initial treatment was nonsurgical followed by standardized orthotic treatment. Foot length growth rate was calculated every half year. In children with unilateral clubfeet, the difference in foot length between the clubfoot and the contralateral foot was calculated. Motion quality was evaluated by the Clubfoot Assessment Protocol (CAP). Student’s t test, the Mann–Whitney U test and Spearman’s correlation were used for group comparisons. Bonferroni correction was used when multiple comparisons were performed. Results: Clubfeet were smaller (P < 0.001) than reference feet at all ages but had a similar growth rate up to age 7. Unilateral clubfeet with greater difference in size compared with the contralateral foot at the first measurement, relapsed more frequently (P = 0.016) and correlated with poorer motion quality (r = 0.4; P = 0.011). Conclusions: As previously reported, clubfeet were smaller than reference feet at all ages. The growth rate, however, was similar between clubfeet and reference feet. Children with unilateral clubfeet and greater foot length difference at 2 years of age had a higher tendency to relapse and poorer motion quality at 7 years of age, indicating that foot length could be used as a prognostic tool