The Scientific Assessment of the Paediatric Foot

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The Scientific Assessment of the Paediatric Foot

• Dr Stewart Morrison
• s.c.morrison_at_uel.ac.uk
• SOCAP Annual Conference, October 2007

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Aims

• To comprehend the scientific principles of
  measurement
• To be able to apply scientific principles to the
  assessment of the paediatric patient
• To acknowledge the influence of scientific
  principles on developing, supporting and
  enhancing patient care

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The Science
1. Systematic experimentation and analysis
1 2 Evidence based Practice
2. Application to current practice recognition
of changing practice
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The goal of the Physician is to accurately and
effectively diagnose and treat an individual
patient. This is a time sensitive process in
which the art of medical practice can be
augmented by learning how to best attain the
maximum research information in an expeditious
manner. Waldman, (2007).
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Principles of Measurement
Describing Quantifying Comparing Interpreting
Diagnosing .

• Clinicians use measurement as a means of
  evaluating a patients condition and response to
  treatment that is, we measure change or
  progress2

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Understand
13 year old female Turners Syndrome Medial ankle
pain
Differentiate
Evaluate
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Clinical Relevance

• Accurate diagnosis
• Continuity of care
• Quality of care
• Efficacy of clinical practice

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• Briefly review the concepts of validity,
  reliability, sensitivity and specificity.
• Apply these principles to your practice, what
  outcomes do you measure, are these suitable?

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Reliability

• the extent to which a measurement is consistent
  and free from error2
• reliability is fundamental to all aspects of
  measurement2

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Validity

• the extent to which an instrument measures what
  it is intended to measure2

• ability to accurately assess the presence and
  absence of the target condition2

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Specificity / Sensitivity

• the tests ability to obtain a negative test
  when a condition is really absent2

• a tests ability to obtain a positive test when
  the target condition is really present2

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Sensitivity
Specificity
Reliability
Validity
Navicular Drop
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Barriers to Scientific Assessment

• Interpretation
• Experience
• Complexity
• Anatomical variation
• The Child
• The Normal
• Time

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Musculoskeletal Foot Examination

• Joint range of motion
• Muscle power
• Biomechanical alignment
• Static dynamic foot function (foot posture
  index, footprint indices)

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Range of Motion

• measures of ankle dorsiflexion in children are
  highly variable 3
• gastrocnemius range of motion is more reliable
  than soleal range of motion 3

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Muscle Power/Spasticity Measures
Level of force?
Duration of force?

• Modified Ashworth Scale
• Modified Tardieu Scale

MRC Muscle Power Scale
Cerebral palsy, Duchennes, JIA
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Forefoot Alignment

• method of visually rating forefoot frontal plane
  deformities is unreliable and of questionable
  clinical value4

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Standing Foot Posture
Foot Posture Index
Anthropometrics
Footprint parameters
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Other areas for consideration

• Gait Analysis
• Pain (VAS)
• Foot Function (FFI)
• Quality of Life (FHSQ)

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Outcomes

• Are the outcomes we use supporting best patient
  care?
• Do the outcomes we use support the development of
  practice?
• Is the evidence base supporting current practice?

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Development of Practice Childhood Obesity
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References

• 1. Waldman, M.H. (2007) The practice of
  evidence-based medicine What it is and why it
  is important. The Foot. 17, pp. 117-118.
• 2. Portney, L.G. Watkins, M.P. Foundations of
  Clinical Research. New Jersey Prentice-Hall
• 3. Evans, A.M. Scutter, S.D. (2006) Saggital
  Plane Range of Motion of the Pediatric Ankle
  Joint. Journal of the American Podiatric Medical
  Association. 96 (5), pp. 418 422.
• 4. Cornwall, M.W, McPoil, T.G., Fishco, W.D.,
  Hunt, L., Lane, C., ODonnell, D. (2004)
  Reliability of Visual Measurement of Forefoot
  Alignment. Foot Ankle International. 25 (10),
  pp. 745 748