Thursday, September 4, 2014

CLUBFOOT AND GLOBAL MOTOR DEVELOPMENT: SOME PRACTICAL CONSIDERATIONS

Along the lines of my Tummy Time essay comes this reflection on the treatment of clubfoot.  As I note, our understanding of clubfoot is very much under evolution.  I have tried to discuss the larger picture of childhood development with clubfoot rather than specifics of clubfoot treatment.  Please let me know your take on this and all of my posts.  ~KPM


The foot is undeniably the pedestal for human balance and ambulation.  Humans depend on the complex interaction of the many joints and ligament structures in the foot to hold up their weight, propel them forward, stop their momentum and cushion their landings.  The emphasis on proper foot function is so strong that it has fostered a billion dollar footwear and orthotics industry that governs what we wear (and don’t wear) and how we play and live.

Because of this overarching significance, great care is placed in early childhood in getting the foot to grow as “normal” as possible.  This care is especially seen in the congenital deformities of the foot, such as talipes equinovarus, also known as clubfoot.

The understanding of clubfoot continues to evolve.  Most experts no longer think that clubfoot is simply a positional abnormality from months of in utero molding.  Although a small subset may be due to extrinsic issues like multiparous conditions, breech positioning and fibroid uterus, the vast majority of clubfeet are now recognized to be a true disruption of the neural axis into the foot, probably arising from the brainstem or even the brain itself.  In other words, clubfoot is a true neuromuscular condition.

The treatment of clubfoot is evolving as well.  Not so many decades ago, the emphasis of early treatment was on loosening the ligaments up so that a child could be more easily repositioned during surgery.  Mixed long-term functional results from surgery as well as the need for non-surgical options in developing countries led to the advent of rigorous casting and bracing protocols, sometimes lasting for many months or longer.  Although there is no clear consensus that the casting techniques are the final word in treatment, nevertheless most children with clubfoot now have an extended course of casting and/or bracing.
 
The issue at hand is that clubfoot itself may pose challenges to a child’s development, even after the foot is realigned.  The treatments themselves are time-consuming and by definition happen during the period of utmost importance in the early motor development of a child.  The casts may span the first six to nine months of life, when a child is typically starting to grapple with crawling and other forms of locomotion and beginning to assay the challenge of upright stance and walking.

It is important to give special attention the motor development in these children throughout the treatment process.  There is a tendency to keep the children lying on their back throughout the treatment to “protect the casts”, but this is both unnecessary and potentially harmful. Parents need to understand not only that milestones may be somewhat delayed by the treatment, but also that they should not be passive about the child’s positioning and function during the treatment.  It is essential, despite casting to allow as much of the child’s general function to develop as possible.

There are a number of strategies which I have incorporated into my treatment protocols which hopefully will minimize the developmental effect of the casting.  First and foremost, I have tried to engage the parents in the child’s positioning as much as possible.  A lot of the early postural development need not be lost to the casting regimen.  Since the casts are typically placed with the knees bent, the all-important curving forward of the body and limbs into what is termed the flexor position need not be disturbed.  Also, the child will still be able to explore side positioning and rolling, although the parents may have to be more active in helping the child position and in clearing the casts over the other leg during rolling.

Since positioning on the baby’s stomach (prone-lying) is so important for the development of arm and hip/ pelvis position and function, I try to place the casts so that there is some active movement available in the knees.  The child should be able to bring the legs under while in the prone position and push off with the arms and hips to get the full benefit of the ground reactive force.   

Another important point is to make full use of whatever time out of the casts might be available.  In point of fact, since it is not the casting, but the interval stretching before casting that is the actual treatment, I find that these timeouts are actually very important in the regimen.  I try to encourage the parents to take full advantage of the time away from immobilization to have the child rolling and prone and to do as much facilitating as possible in the brief respites.  In the early stages of the casting, I will use a material that the parents can remove the day before the next stretching/ casting treatment.  This not only allows the parents to bathe the child thoroughly but also give an extended period of attention to motor stimulation.  I have also talked to parents about specific techniques like brushing to stimulate the child’s awareness of the feet during the periods out of the casts.  These same techniques can also be done while the child is the cast since the toes and forefoot are exposed.

An interesting technique I have incorporated recently has been cast application in a bouncy seat.  Not only does this help the child to relax during the cast application.  It also allows the child to maintain a flexor posture better than placement of the cast in the fully flat position typically used.  My hope is that the child will accommodate to the cast as part of the more natural flexor positioning.  Early results in terms of acceptance of the cast by the child and maintenance of leg function have been encouraging.

In summary, the most important point is to not allow the casting regimen to dominate the child’s function.  The parents can and should be instructed to be as active in the child’s development as they would be if the child were not casted.  And special exercises and activities should be used to take advantage of every moment that the child is freely mobile.

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