csp_skipp_talipes

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CSP SKIPP Evidence Note 01 (2009) Talipes x

Phytherpy Mgemet

f Pt Tpe Equru

TaliPEs

CsP EvidEnCE noTE 01Issue date: August 2009


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Phytherpy Mgemet f Pt Tpe Equru

2 CSP SKIPP Evidence Note 01 (2009) Talipes

Key poits

1 No agreed denition of positional talipes equinovarus

(PTEV) was identied

2 There was limited cosesus o the methods of

cliical assessmet used

3 Further research is required o the deelopmet of

standardised assessment tools for the identication of

PTEv

4 no eidece-based coclusios ca be reached o

the effectieess of physiotherapy iteretio i the

maagemet of PTEv

impct

1 a there tte eece upprtg r refutg

phytherpy tretmet f PTEv, phytherpt

hu ctue ther curret pr.

2 Fr the wh therefre ctue t pre

phytherpy tretmet f PTEv, t juge

the effect erce pr tretmet,

phytherpt hu recr the preece f

bbe wth PTEv referre fr emet, receg

tretmet, the teret ue utcme,

we the tme pet ct-effectee f y

teret. a tre t cect frm

h bee crete: www.cp.rg.uk.

3 Whe cectg th t, phytherpt mut

ensure the gures for PTEV are separated from the

ther pt ft ct.

4 There ee t be eut f the pychmetrc

prperte f the emet t fr PTEv.

5 Pret p hu be ught the fferet

teret ee.

6 The operational denition used within this Evidence

nte hu be ue t eure ctecy trt.

A SKIPP Evidence Note is a research evidence summary, which seeks to provide pointers for further research and clinical

practice. This collation presents the best available evidence in the view of the authors. This follows careful considerationof all the evidence available. The SKIPP process has been developed to provide a structure for the development of

evidence-based documents in physiotherapy. For more information on the SKIPP work programme, see www.csp.org.uk.

All products undergo a process of independent review before endorsement by the Chartered Society of Physiotherapys

Good Practice Panel. Healthcare professionals are expected to take it fully into account when exercising their clinical

judgment. However, the Evidence Note does not override the individual responsibility of healthcare professionals to make

decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or

carer. Implementation of this guidance is the responsibility of local commissioners and/or providers.

Developed by the Association of Paediatric Chartered Physiotherapists, Neonatal Care Clinical Group

Denise Hart MSc, MCSP, Pat Dulson Grad Dip Phys, MCSP, Jennifer Poole Grad DIp Phys, MCSP,

Adare Brady MClin REs, MCSP, Dr Lisa Roberts PhD, MCSP

For inquiries relating to the content of this Evidence Note, please contact Ms Denise Hart MCSP,

Senior Physiotherapist, Southampton NHS Trust: [email protected]

This document should be referenced as Hart D (2009) Physiotherapy Management of Positional Talipes Equinovarus,

Evidence Note 01, Chartered Society of Physiotherapy, London


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Bckgroun

Tere are two types o talipes equinovarus that newborn babiesmay present with: Congenital talipes equinovarus (CEV), also known as xed

or structural talipes Positional talipes equinovarus (PEV).

CEV is a complex oot deormity consisting o equinus, varus,adductus and medial rotation (1). It includes the presence oa bony deormity. Te reported prevalence is 1-2 per 1000 livebirths (1, 2). Within the literature, treatment includes the Ponsetimethod (1), strapping, casting and possibly surgical correction

(2).

PEV: Although no standardised denition exists, its reportedprevalence is 16 per 1000 live births (3). It includes the absenceo a bony deormity. It has been described either as a conditioncaused by malposition in utero (1, 4, 5, 6, 7) or a condition thatis part o the structural spectrum (8, 9).

Within the literature, the assessments used by physiotherapistsor PEV and CEV are identical although they were originallydeveloped or the assessment o CEV (10-15). Te two mostcommonly used assessment tools are those developed by Piraniand Dimeglio (10, 15). Te Pirani assessment is used both

nationally and internationally. Furthermore, although it ispartially available in reely accessible articles (12, 17, 18), it hasnever been published in a peer-reviewed journal.

A survey o physiotherapy practice or PEV, undertaken in2006, revealed that the physiotherapy management is historicaland anecdotal, rather than evidence-based, and ranges rom notreatment to stretches and stimulation shown to the parents,(with or without ollow-up) and in some cases, strapping ororthotics. In addition, exercise leaets are given to the parentsin some areas (3). Te extent o ollow-up also varies rom onevisit to the babies being reviewed until they are walking (3). Ibabies with PEV are to be treated by physiotherapists, there

needs to be a exibility in service provision due to reductions inpost-natal length o stay:In 2005/6 it was reported that 51% o women went home eitheron the same day or the day aer giving birth, compared with 21%in 1989/90 (19). Consequently the physiotherapist has to allocatetime in case o reerral, or prioritise these patients (based onservice delivery constraints as opposedto clinical need) or organise an outpatient appointment or thebaby.

Tereore with changes in service delivery, it is important thatphysiotherapists use valid and reliable assessment tools and adoptevidence-based treatment strategies. o date however, there isno published guidance on the physiotherapy assessment andtreatment or babies presenting with PEV, hence the need orthis review.

aims

Te purpose o this evidence note is to collate the evidence orphysiotherapy assessment and treatment or babies with PEVand identiy the gaps in the evidence base.

Operational defnition

For this project PEV was dened as a oot held in the alipesEquino Varus position that was passively correctable whendiagnosed at the babys rst medical examination within the rst

72 hours o birth. It includes the absence o a bony deormity.While there is a great deal o natural variation there should beat least 20 o dorsiexion about the ankle in the sagittal plane(10). Tere are no measurements available or the other planeso movement. Comparison can also be made with the unaectedside in unilateral PEV.

Methos

A search was perormed using Amed, British Nursing Index,Cinahl, Cochrane, Embase, Google, ISI Web o Knowledge,

Maternal and Inant Care, Medline, National Library o Health,National Research Register, PEDro and SEPS databases rom1963-2008. Te key words used in the search strategy were:assessment, cluboot, newborn oot deormities, physiotherapy,positional talipes, positional EV, postural talipes, posturalEV, talipes, talipes equinovarus. Hand searches were alsoperormed o any articles ound and o the Journal o theAssociation o Paediatric Chartered Physiotherapists. Te resultsrom a national survey o current physiotherapy practice in thetreatment o talipes (3) were also included.

nInclusion Criteria for Review

Papers included in the review were written in English, orpragmatic and cost reasons, and addressed either the assessmento talipes equinovarus (PEV or CEV) or the physiotherapymanagement o PEV.

nExclusion Criteria for ReviewPapers dealing solely with the treatment o CEV, calcaneovalgus,metatarsus varus and vertical talus.

Note that papers describing common oot conditionswere included in the background section but were notincluded in the review, as they did not ull the inclusioncriteria.

All members o the working party reviewed the papers oundusing the Critical Assessment Skills Programme (CASP) (20).

CSP SKIPP Evidence Note 01 (2009) Talipes 3


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Phytherpy Mgemet f Pt Tpe Equru

4 CSP SKIPP Evidence Note 01 (2009) Talipes

Author Year Assessment/

purpose

of study

Subjects Key measures Training Psychometric

Properties

Catterall

(11)

1990 Method o

assessment o

the club oot

deormity

None 4 patterns described depending on evolution o deormity

classied as resolving pattern, tendon contracture, joint

contracture or alse correction; 9 measurements to assess

the xed deormity and range o movement

Calf: tibial torsion (degrees), maximum cal measurement

(cm), length o oot (heel to great toe cm)

Hind foot: range o movement, lateral malleolus posterior

(Y/N)

Fore foot: lateral border o oot: straight/curved (degrees)

corrects in equinus Y/N, creases: posterior/anterior/medialBoth: presence o: cavus Y/N, supination (degrees)

Not

reported

Validity not

reported

Reliability not

reported

Sensitivity to

change not

reported

Ponseti

et al (23)

1963 Congenital

club oot:

the results o

treatment

(severe cases

only)

67

babies

94 eet

Ankle dorsifexion (degrees), Heel varus (degrees)

Adduction o oreoot (degrees), Tibial torsion (degrees)

Anteroposterior and lateral roentgenograms and

photography at onset o treatment and at nal examination

All clinical measurements taken by Ponseti or uniormity

Not

reported

Validity not

reported

Reliability not

reported

Sensitivity to

change not

reported

Dimeglio

et al (10)

1995 Classication

o cluboot

171 eet 4 grades based on 4 essential parameters: equinus

deviation in sagittal plane, varus deviation in rontal plane,

derotation o calcaneo-oreoot block in horizontal plane,

adduction o oreoot relative to hindoot in horizontal

planeGrade I: Benign (score < 5), Grade II: Moderate (score 5 to

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